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The role of private hospitals in South Africa. Part I. Current trends.

This paper is the first of two that examine the present and the future role of private hospitals in South Africa. Part I describes the current structure and size of the private hospital sector, and analyses recent trends in the number and distribution of beds and hospitals, expenditure patterns, and utilisation of care. These observations are used as the basis for an analysis of the present role of the private hospital sector. It is argued that this sector is an important potential national resource for health care. However, the present contribution of private hospitals to national health care is limited by several factors. Access to a large proportion of these hospitals is restricted to those who can afford to pay, while the economic inefficiency and geographical maldistribution of fee-for-service and charity hospitals compound the negative effect private hospitals have on the public health sector. The gap between the potential contribution of private hospitals and current reality provides a strong argument for the development of a national policy that will improve the situation.

Hospital Bed Capacity↗

Benchmarking the quality of schizophrenia pharmacotherapy: a comparison of the Department of Veterans Affairs and the private sector.

BACKGROUND: Comparing quality of care between large health care systems is important for health systems management. This study used measures of the quality of pharmacotherapy for patients with schizophrenia and compared these measures across a sample of patients from the Department of Veterans Affairs (VA) and the private sector. METHODS: A random sample of all patients diagnosed with schizophrenia in the VA during fiscal year (FY) 2000 was identified using administrative data. In the private sector, a sample of patients diagnosed with schizophrenia in 2000 was identified using MEDSTAT's MarketScan database. For both groups, use of antipsychotic medications was studied and measures of the quality of pharmacotherapy were constructed, including whether patients were prescribed any antipsychotic medication, one of the newer atypical antipsychotics, and whether dosing adhered to established treatment recommendations. These measures were compared across the two groups using logistic regression models, controlling for age, gender, and comorbid diagnoses. RESULTS: Most patients with a diagnosis of schizophrenia (82% in the VA and 73% in the private sector) received an antipsychotic medication, usually one of the newer atypical drugs. Patients in the VA were more likely to be dosed above treatment recommendations, and less likely to be dosed below treatment recommendations. Overall, differences in proportion schizophrenia patients dosed according to recommendations were not statistically different across the two systems (60% in the VA, 58% in the private sector). CONCLUSIONS: Differences between the two systems were mixed, with the VA outperforming the private sector with respect to some measures and doing worse on others. IMPLICATIONS FOR HEALTH CARE PROVISION: Although the VA and the private sector were comparable with respect to the quality measures used in this study, there is room for improvement in both systems. Treatment recommendations are based on the best available clinical evidence of effectiveness and safety. Quality of care might be improved with better adherence to these recommendations. IMPLICATIONS FOR HEALTH POLICIES: Relatively low rates of adherence to treatment recommendations may be due to lack of awareness of these recommendations among prescribing physicians, or a belief that the recommendations are inadequate. To the extent that low rates of adherence to treatment recommendations are caused by a lack of awareness among physicians, policies should be developed to disseminate this information and encourage the appropriate use of these medications. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed to understand physician prescribing decisions for these medications. To the extent that physicians feel treatment recommendations for these drugs are inadequate, further research is needed to refine the recommendations.

Antipsychotic Agents↗

Health disparities between diabetic patients under private and public health coverage in Puerto Rico, 2000.

OBJECTIVE: To examine health disparities between diabetic patients receiving services in private and public health sectors. METHODS: Insureds with service claims for diabetes (ICD-9 250-259) from two private insurance companies and two public health groups were selected. Personnel of the participant insurance companies were responsible for identifying medical claims that met the study inclusion criteria and providing the information in a computerized database file. RESULTS: Overall prevalence was 4.9%. Prevalence in the public sector (5.8%) was higher than that of the private sector (3.7%) (p < 0.0001). The overall prevalence among females of the public sector was nearly twice (6.3%) the prevalence in the private sector (3.3%) (p < 0.0001). The prevalence of the majority of services analyzed was larger in the public sector. However, prevalence of specific services (glucose and glycosilated hemoglobin tests) was larger in the private sector. Differences between sectors in the prevalence of complications were also observed. Prevalence and service utilization also varied by age and sex in both sectors. CONCLUSIONS: Significant difference exists in the prevalence of diabetes and health service utilization between the private and the public sector.

Adolescent↗

Assessment of quality of services in private clinics in Addis Ababa, Ethiopia.

Involvement of the private sector in provision of health services has progressively increased in many developing countries including Ethiopia. Promotion of the private sector involvement is also one of the elements in the health care financing strategy in Ethiopia. A cross sectional descriptive study was done on quality of care in private clinics in Addis Ababa during the period of April, 2000. Different levels of clinics were randomly selected and assessments were done on structural aspects, performance of health workers in polyclinic outpatient department and patients satisfaction with the medical care given. It was found that most clinics fulfill the requirements of the Ministry of Health (MOH) with regard to staffing, equipment and medications. Nevertheless few clinics were found not to fulfill the minimum requirements put in the guideline. With regard to performance, various aspects of mal-performance were observed where the highest problem was concerning treatments given to patients. High rates of satisfaction were generally reported in all aspects of medical care that include: waiting time, cleanliness of facilities and equipment, courtesy and competence of providers and the effectiveness of the services provided. Relatively lower proportion of respondents has reported dissatisfaction with the services provided. The aspects of the private sector services for which dissatisfaction was reported were too high service charge and too little information given about nature and prospect of diseases. These imply that the private facilities included in the study are generally doing well in terms of structural as well as in most process attributes of quality while provider-patient interaction and competitive pricing of services seem to be areas that need improvement. Findings are discussed in comparison with findings in public and private health facilities in Ethiopia and other countries. In addition, the inclusion of periodic assessment of process of care in quality control measures is recommended.

Ambulatory Care Facilities↗

Brazilian National Standard for Electronic Form Interchange among Private Health Plan and Healthcare Providers.

Since 1988 the Federal Constitution of Brazil declared health care as a public right to be provided as a duty of the state(1). Thus the Unique Public System ("Sistema Unico de Saúde-SUS"), Ministry of Health, a comprehensive health care system with full coverage, was created since then. But the private sector has nevertheless also been operating since 1960s but without any government regulation at all. It serves approximately twenty-five per cent of the Brazilian population (estimated at 180 million of people).The National Supplementary Health Agency - NSHA ("Agência Nacional de Saúde Suplementar- ANS") was created in 2000 and is in charge of regulating and assisting the private health plan organizations. The public sector has been structuring its information systems for almost 15 years, defining standard schemes, such as the National Health Card Project, in order to institute a national unique identifier health care and to construct a national repository of health records.The lack of widely common information standards in the private sector, however, and the difficulties involved in the complex information interchange among private health plan organizations and health providers have caused NSHA to work out a proposal for a national standard for electronic form interchange proposal, based on XML technology, known as the supplementary health information interchange (TISS - "Troca de Informação em Saúde Suplementar"). The TISS project aims integrating healthcare information nationwide; therefore it was developed in accordance with the National Health Card Project, using the same unique identifiers and others standard sets proposed by the Ministry of Health, such as unique identifiers of providers.NSHA has presented the TISS project successfully to all stakeholders and is going to introduce legislation to enforce the standards. There are more than two thousands private health plan organizations in the whole country and more than ten thousands hospitals and clinics. Private health practioners, including dentists, will also have to adopt the standard. As a matter of fact, the TISS project not only focuses on the patient billing but also on epidemiological information. And the TISS project is not only for health provider claims, but also to all kinds of events such as consultation and exams.

Brazil↗

[Physiotherapists in private practice in France].

In France, most of the physiotherapists providing ambulatory care are in private practice: they are paid on a fee-for-service basis by the patients who are reimbursed by the Sickness Insurance Fund. A survey on a sample of 2000 (out of 40,000) private practitioners was undertaken in early 2004. As concerns their workload, only 4% think that it is "not sufficient" whereas 66% estimate it "certainly sufficient". Such a feature is noteworthy, as private practitioners are most often fearful of lack of work. In the coming years, one physiotherapist out of 10 envisages to increase his workload, whereas 27% are in favour of a reduction. Furthermore, the survey shows that more than one third of private physiotherapists plan to offer to patients services which are not listed in the contractual agreement document signed by their profession and the Sickness Insurance Fund. The trend is most noticeable among the young practitioners. As the feeling of medical doctors shortage is currently widespread in France, the public debates are focused on the issue of task delegation. After the survey, 54% private physiotherapists are in favour of task delegation, 24% have an opposite opinion and 22% do not express a clear-cut position. However, an in-depth analysis of the written answers to the question shows that a large majority do not accept to replace medical doctors for performing the tasks which are of a subordinate level, are not significant or are time-consuming (e.g. filling out the administrative forms). The question of vocabulary is fundamental in the matter. Moreover, a process of task delegation implies that certain tasks carried out by an overburdened profession are transferred to an other profession less heavily surcharged. Is it the case of French private physiotherapists whose two thirds declare that "their workload is certainly sufficient"?

Adult↗

Efficacy of hepatitis B screening in a private obstetrical population.

We sought to determine whether the recent Centers for Disease Control recommendation of universal prenatal screening for hepatitis B surface antigen (HBsAg) is necessary or cost-effective in a population of private patients. During the 21 months of our study there were 17,973 deliveries at Magee-Womens Hospital, the largest-volume private obstetrics service in the United States. We screened 12,377 of these patients for HBsAg. Only 11 patients, 0.09% of those screened (5 private and 6 clinic) tested positive. We administered questionnaires regarding historical risk factors for hepatitis B to all 11 patients testing positive for HBsAg and to 100 controls who tested negative for HBsAg. All private patients and 5 of 6 clinic patients testing positive for HBsAg had identifiable risk factors for hepatitis B. In addition, historical risk factors for hepatitis B were identified in 29% of the women testing negative for HBsAg. We found historical risk factors to be excellent predictors of the presence of HBsAg in our private patients. Our data indicate that universal screening for HBsAg is not necessary in private patients.

Cost-Benefit Analysis↗

Private practice may be good for your health and well-being.

During the past decade, the growth in private practice has generated considerable debate in the social work profession on values and mission. Much of this debate has focused on whether social workers should enter private practice. Not as much research has been done on why social workers enter private practice. Using national random samples drawn from 1985 NASW membership records, this study compares the personal well-being of individuals who are in full-time private practice with the personal well-being of individuals who are in full-time agency practice. On all measures of personal well-being used in the study, workers in private practice fare significantly better than their colleagues in agency settings. The authors suggest that personal well-being may be one of the factors leading social workers into private practice. Additional implications also are suggested.

Burnout, Professional↗

The effect of faculty private practice experience on appropriate charging for professional services.

Private practice experience is widely considered invaluable for academic family physicians, especially for clinical efficiency and for charging appropriately for professional services. This study tested the hypothesis that faculty members with private practice experience charged more appropriately for professional services. Patient-physician encounters were rated in terms of propriety of charges by consensus of two faculty physicians and compared to the actual level of service marked on the encounter form. Private practice experience for faculty resulted in less undercharging (21% of encounters undercharged versus 31% for faculty without that experience, P = .03). Physicians with private practice experience undercharged on average $.36 per encounter, versus $1.94 for providers without that experience (Kruskal-Wallis test, P = .27). Physicians with private practice experience also tended to perform more procedures but not to bill for more. Academic family physicians with private practice experience demonstrated more appropriate billing practices for professional services, but ideally preference for this type of academic physician should be based on other attributes, such as breadth of experience and efficiency in patient care.

Faculty, Medical↗

Relationships between public and private providers of health care.

Fifteen local health departments that were identified as notable for their involvement in rendering personal health care were intensively studied along with their communities. Interviews with local medical care leaders and practitioners provided much of the study data. Three patterns characterized the relationships between the health departments and private providers in the communities. In one pattern, there were dual or parallel systems of care, both public and private, which were self-contained, with little planned linkage between them. In another pattern, the public and private sectors were interactive, relying on each other in deliberate ways for the exchange of services. In a third pattern, termed accommodative, the private and public sectors, although maintaining service separation, planned with each other for the establishment of complementary programs that would be responsive to community needs. Provision of health services of high repute was associated with all three of these patterns. Although tensions were not absent between public and private providers in the study communities, a climate of mutual support and good will appeared to characterize their relationships. In none of the health departments selected as outstanding, was an atmosphere of conflict with the private medical community reported.

Community Health Services↗

The benefits of privatization.

The promise of a universal, comprehensive, publicly funded system of medical care that was the foundation of the Medical Care Act passed in 1966 is no longer possible. Massive government debt, increasing health care costs, a growing and aging population and advances in technology have challenged the system, which can no longer meet the expectations of the public or of the health care professions. A parallel, private system, funded by a not-for-profit, regulated system of insurance coverage affordable for all wage-earners, would relieve the overstressed public system without decreasing the quality of care in that system. Critics of a parallel, private system, who base their arguments on the politics of fear and envy, charge that such a private system would "Americanize" Canadian health care and that the wealthy would be able to buy better, faster care than the rest of the population. But this has not happened in the parallel public and private health care systems in other Western countries or in the public and private education system in Canada. Wealthy Canadians can already buy medical care in the United States, where they spend $1 billion each year, an amount that represents a loss to Canada of 10,000 health care jobs. Parallel-system schemes in other countries have proven that people are driven to a private system by dissatisfaction with the quality of service, which is already suffering in Canada. Denial of choice is unacceptable to many people, particularly since the terms and conditions under which Canadians originally decided to forgo choice in medical care no longer apply.

Canada↗

Comparison of drug utilisation in public and private primary health care clinics in Tanzania.

A study was carried out in 20 public and 20 private out patient clinics (dispensaries) in Dar es Salaam. At least 30 prescriptions were collected from each clinic. A total of 1200 were collected for analysis. Prescribing indicators from the WHO/DAP "how to investigate drugs in health facilities" were used. The average number of drugs per prescription in public clinics was 2.2 compared to 2.5 in private ones (p > 0.05). The percentage generics was 51.7 in public clinics against 47.7 in private (p > 0.05). On the other hand the percentage of antibiotics was 12.3 in public against 19.7 in private (p < 0.05) whereas injections percentage was 9.6 in public against 12.7 in private clinics (p < 0.05). The results suggest a need for intervention to curb the irrational use of antibiotics and injections in private clinics.

Ambulatory Care Facilities↗

Privatization of the medical market in socialist China: a historical approach.

A Socialist-Market Economy was defined as a target model for China's economic reform by China's 14th National Congress in 1992. Such an innovative change in China's more than a decade long economic reform has brought both new challenges and opportunities for its health care system reform as it moves toward a market determination mechanism and involvement of the private sector. A better understanding of the nature and history of the Chinese private medical market and its dynamic socio-economic environment would certainly shed a great deal of light onto the accomplishments of the health care reform. Research in this area, however, is almost non-existent at either national or international levels. The present study attempts to fill this gap by providing a comprehensive assessment of both historical and prospective development of the Chinese private medical market. Three stages are defined to present the tortuous development of this market over the last four decades, coupled with our critiques of the underlying merits and problems. Predictions are also made on the future perspective of the private market, and its possible impact and role in shaping the reform of the entire Chinese health care system. The government's role as well as its future strategy to cope with the issues surrounding Chinese health care reform are also summarized. The study concludes with five health policy recommendations aimed at facilitating China's health care reform via more market-oriented determination of resources allocation, production, and distribution, coupled with promotion of the private sector's involvement while minimizing its potential adverse side effects.

Ambulatory Care Facilities↗

The quality of public and private pharmacy practices. A cross sectional study in the Savannakhet province, Lao PDR.

AIM: The aim was to study the practices of public and private pharmacies in the Savannakhet province, Lao PDR, in relation to defined aspects of good pharmacy practice (GPP) and rational use of drugs (RUD). STUDY DESIGN: The study design was cross-sectional using structured interviews and observations. A total of 105 drug sellers (31% and 4% had pharmacy education at public and private pharmacies, respectively) were interviewed, and the pharmacies were inspected. In addition, 576 customers were interviewed immediately after the drug transaction and all their drug purchases were recorded. Facility, patient-care and prescribing indicators covering aspects of GPP and RUD were used to measure and compare the quality of services of the pharmacies. RESULTS: The results showed that public pharmacies differed significantly from private pharmacies, with lower mean scores for availability of essential drugs (5.1 vs 6.4), 95% confidence interval (CI -2.23, -0.34) and essential materials (5.6 vs 6.9, 95% CI -2.40, -0.20), and with a higher percentage of antibiotics dispensed (34% vs 24%, P<0.02), as well as more injections (31% vs 7%, P < 0.001) and drugs per customer (2.4 vs 1.4, 95% CI 0.84, 1.16). More drug purchases were decided by health workers at public pharmacies than at private pharmacies (92% vs 16%). At public pharmacies, significantly more drugs were prescribed from the National Essential Drug List (76% vs 56%, P=0.004), and more drugs had an international non-proprietary name (67% vs 35%, P<0.001). There was no significant difference regarding order in the pharmacy, oral information and drugs adequately labelled at the public pharmacies compared with the private pharmacies. CONCLUSION: In spite of the differences shown, both public and private pharmacies performed suboptimally in relation to several aspects of GPP and RUD. The lack of essential drugs, essential materials, information on drug use and adequate drug labelling all contribute to irrational use of drugs. Interventions are needed to improve practice and drug use.

Adult↗

Age-related changes in preschool children's systematic use of private speech in a natural setting.

This study set out to explore the contexts in which preschool children use private speech, or self-talk, in the naturalistic setting of the preschool classroom, and age-related changes in the contexts in which preschoolers talk to themselves. A total of 2752 naturalistic observations of fourteen three-year-old and fourteen four-year-old children were conducted using a time-sampling procedure in two preschool classrooms over the course of one semester. Results from logistic regression analyses revealed that both age groups were (a) more likely to use private speech during the self-selected activity classroom context as opposed to both large group and outside free play classroom contexts, and (b) most likely to talk to themselves when alone, next likely in the presence of peers, and least likely when in the presence of a teacher. Although the probability of private speech among three-year-old children did not vary as a function of the child's immediate activity, four-year-old children's private speech was more likely to occur during sustained and focused goal-directed activity as opposed to rapidly-changing and non goal-directed activity. The findings suggest that private speech appears systematically in young children and that, in several ways, four-year-old children use private speech more selectively than three-year-olds.

Adult↗

Private psychiatric hospitals, United States: 1983-84 and 1986.

In 1986, a total of 314 private psychiatric hospitals provided inpatient services in 47 States and the District of Columbia (D.C.); 114, outpatient care services in 35 States and D.C.; and 102, partial care services in 26 States and D.C. Between 1983 and 1986, the total number of inpatient, outpatient, and partial care episodes in these hospitals increased from 333,731 to 483,284. During the 1983-86 period, the number of private psychiatric hospitals increased from 220 to 314. Almost all of this increase occurred among hospitals operating on a for-profit basis. By 1986, these hospitals represented three-quarters of all private psychiatric hospitals. With the exception of small not-for-profit hospitals, all bed-size groups in private psychiatric hospitals increased between 1983 and 1986. The number of beds in private psychiatric hospitals increased 41 percent, from 21,474 in 1983 to 30,201 in 1986. Similarly, the number of inpatient additions increased from 164,732 to 234,663 in this period, and inpatients at end of year increased from 16,079 to 24,591. The number of outpatient additions increased by more than half, from 77,589 in 1983 to 123,355 in 1986, and the outpatients at the end of the year rose from 79,598 to 135,606 (70 percent). In the same period, the number of partial care additions increased from 5,642 to 8,820, and partial care patients at the end of the year rose from 3,218 to 3,856 (20 percent). In the 1986 year-end inpatient caseload, males slightly outnumbered females, and the patient population was predominantly white, non-Hispanic. About two-fifths of the patients were under age 18, slightly over half were age 18-64 years, and 8 percent were age 65 or older. Mental illness was the major disability, with alcohol and drug abuse a distant second. By comparison, a smaller proportion of patients were under age 18 in 1983 (31 percent), and a larger proportion were age 18-64 (61 percent). In outpatient and partial care services, a more even distribution of the sexes was generally observed. Proportionately fewer outpatients were under age 18, more were between 18 and 64, and fewer were diagnosed with alcohol and drug abuse, compared with inpatient services. Also, proportionately more outpatients were Hispanic. Concomitant increases occurred in the number of full-time equivalent (FTE) staff, as well as in the amount of money expended by private psychiatric hospitals. FTE staff increased from 42,202 in June 1984 to 58,912 in November 1986.(ABSTRACT TRUNCATED AT 400 WORDS)

Cross-Sectional Studies↗

Ownership and mental-health services. A reappraisal of the shift toward privately owned facilities.

The mental-health system in the United States is undergoing marked "privatization"--a growth in the importance of both private nonprofit and for-profit providers. Analyzing data collected in earlier surveys, we found that the type of ownership was linked to a number of important aspects of institutional performance: (1) private facilities, both for profit and not-for-profit, are more likely to screen out nonpaying patients than are government-owned providers; (2) services provided under public auspices are more expensive than those provided in private institutions; and (3) compared with private nonprofit facilities, for-profit providers devote fewer staff resources to patient care and offer fewer services with community-wide benefits. We conclude that ownership affects the organizational behavior of mental-health facilities. The contemporary shift from public to private provision of mental-health care raises important questions about ensuring adequate access to care, maintaining the supply of needed services, and adapting systems of reimbursement and regulation to the heterogeneous motivations of providers operating under different forms of ownership.

Community-Institutional Relations↗

Private and public in the lives of chronic schizophrenic patients.

This article argues that both the private and public spheres must be taken into account when analyzing the development and everyday reality of the mentally ill. Private and public are two poles whose reciprocal relationship constitutes the form taken by a person's life. The interplay of both areas expresses how a person uses his thinking, feeling, and acting to relate to a real or imaginary audience. The psychosocial reality of a person is based on cooperation of the public and private selves. According to a central thesis of this essay, a loss of public presence leads in equal measure to a loss, rather than an increase, of private reality. An empirical study based on a sample of patients with chronic schizophrenia confirms this assumption by showing that such patients, under today's social conditions, develop lives characterized by a high degree of private reclusiveness. This is linked with an external and internal loss of life reality. Many patients, however, look for indirect and socially noncommittal forms of participating in public life without having to deny their private reality.

Adaptation, Psychological↗