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PubMed2005

Managing uncertainty around HIV/AIDS in an urban setting: private medical providers and their patients in Pune, India.

Changing epidemiological patterns and the advent of new rapid diagnostic technologies and therapies have created considerable uncertainty for providers working in HIV. In India, the demand for HIV care is increasingly being met by private practitioners (PPs), yet little is known about how they deal with the challenges of managing HIV patients. To explore HIV management practices in the private medical sector, a survey was conducted with 215PPs in Pune, India, followed by in-depth interviews focusing on the social context of practice among a sub-set of 27PPs. Drawing primarily on interview data, this paper illustrates a number of uncertainties that underlie the reported actions of providers in a competitive medical market. PPs perceive HIV as a 'new' and challenging disease for which they lack adequate knowledge and skills. Combined with the perceived high cost and complexity of antiretroviral treatment, preconceptions about HIV patients' social, financial and mental capacity lead to highly individualistic management practices. While these fall short of clinical 'best practice' guidelines, they reflect adaptive responses to the wider uncertainties surrounding HIV care in urban India. By highlighting contextual issues in PPs' management of HIV patients, the paper suggests the need to explicitly acknowledge the social, moral and economic bases of uncertainty beyond the clinical setting.

Antiretroviral Therapy, Highly Active↗
PubMed2006

Building effective public-private partnerships: experiences and lessons from the African Comprehensive HIV/AIDS Partnerships (ACHAP).

This paper examines the processes for building highly collaborative public-private partnerships for public health, with a focus on the efforts to manage the complex relationships that underlie these partnerships. These processes are analyzed for the African Comprehensive HIV/AIDS Partnerships (ACHAP), a 5-year partnership (2001-2005) between the government of Botswana, Merck & Co., Inc. (and its company foundation), and the Bill & Melinda Gates Foundation. ACHAP is a highly collaborative initiative. The ACHAP office in Botswana engages intensively (on a daily basis) with the government of Botswana (an ACHAP partner and ACHAP's main grantee) to support HIV/AIDS control in that country, which had an adult prevalence of 38.5% HIV infection in 2000 when ACHAP was being established. The paper discusses the development of ACHAP in four stages: the creation of ACHAP, the first year, the second and third years, and the fourth year. Based on ACHAP's experiences over these four years, the paper identifies five lessons for managing relationships in highly collaborative public-private partnerships for public health.

Botswana↗
PubMed2006

The double burden on safety net providers: placing health disparities in the context of the privatization of health care in the US.

The US Institute of Medicine's (IOM) influential 2003 report has focused attention on disparities in treatment outcomes and health status for American minorities, zeroing in on the role of unconscious bias in the unequal clinical disposition of minority patients. In keeping with the IOM's focus, current examinations of health disparities in the US tend to explore bias in clinical decision-making to the neglect of the political economic trends that buffet health care safety net sites and create the need for financial shortcuts. This paper recontextualizes the study of health disparities in the US by placing it against the backdrop of private sector trends emphasizing fiscal austerity and increased workforce productivity in health care. The social science literature on workers in human service bureaucracies, only recently applied to health care workers, suggests that higher demands for system "accountability" and worker "efficiency" may encourage providers to take shortcuts by treating individuals as mass categories. This ethnography of a Latino mental health clinic in the Northwestern USA shows that new private-sector measures of "productivity" take a toll on both the Latina clinicians whose invisible work subsidizes the system as well as on particular categories of patients--the uninsured and immigrants with serious psychosocial issues. While clinicians attempt to buffer the impacts of such reforms on patients, they also resort to means to increase their productivity such as firing repeated no-show patients and denial of care to the uninsured. This study is relevant for the health care of the poor in all health care systems considering restructuring along managerial principles to increase system 'efficiencies.'

Community Mental Health Services↗
PubMed2006

Seven habits of highly effective global public-private health partnerships: practice and potential.

Global public-private health partnerships (GHPs) have become an established mechanism of global health governance. Sufficient evaluations have now been conducted to justify an assessment of their strengths and weaknesses. This paper outlines seven contributions made by GHPs to tackling diseases of poverty. It then identifies seven habits many GHPs practice that result in sub-optimal performance and negative externalities. These are skewing national priorities by imposing external ones; depriving specific stakeholders a voice in decision-making; inadequate governance practices; misguided assumptions of the efficiency of the public and private sectors; insufficient resources to implement partnership activities and pay for alliance costs; wasting resources through inadequate use of recipient country systems and poor harmonisation; and inappropriate incentives for staff engaging in partnerships. The analysis highlights areas where reforms are desirable and concludes by presenting seven actions that would assist GHPs to adopt better habits which, it is hoped, would make them highly effective and bring about better health in the developing world.

Cooperative Behavior↗
PubMed2005

Drug discovery and beyond: the role of public-private partnerships in improving access to new malaria medicines.

Traditional pharmaceutical research and development (R&D) strategy has failed to address the desperate need for new antimalarial drugs. The populations affected are too poor to attract commercially-driven R&D. Over the last few years, a new model, the public-private partnership for product development, has radically changed the antimalarial R&D landscape. The partnerships bring together academic and industry expertise with funding from governmental, philanthropic and charitable sources. The Medicines for Malaria Venture, a not-for-profit foundation based in Geneva, aims to develop new antimalarials for developing countries through public-private partnership. It is currently managing a portfolio of around 20 projects at various stages of development. However, as in all drug R&D, some of these projects will fail. The portfolio approach helps to maximize the chances of success, but there are obvious challenges, including financial and managerial ones. Proactive management of the two vital interfaces in the drug supply chain is important for success. Upstream, basic research must be aligned with translational research in order to ensure a continuous supply of leads into the development pipeline. Meanwhile, downstream, drug discovery and development must be aligned with access to ensure optimal health impact. All stages require partnership, sustainable financing and the engagement of disease-endemic countries. The recent G8 report on Africa has lent support to mechanisms aimed at improving health and achieving the Millenium Development Goals.

Antimalarials↗
PubMed2005

Public-private partnerships: an overview.

The development and marketing of medicines needed specifically to combat diseases of the developing world are commercially unattractive because the populations concerned are among the poorest on earth. Partnerships which bring together pharmaceutical companies, academics, not-for-profit organizations, philanthropists, governmental and inter-governmental agencies are an increasingly popular solution. These partnerships result in a complementarity of skills and resources that can accelerate the development and delivery of new medicines to those in need. Over the last 10 years or so, these public-private partnerships (PPPs) have grown significantly in number and diversity. However, they tend to cluster into two main groups: those dealing with product development (PD PPPs), and those concerned with improving the access of new medicines to target populations (Access PPPs). The Initiative on Public-Private Partnerships for Health was set up four years ago to monitor the performance of these new partnerships. After a series of studies of Access PPPs, it concluded that they provide significant benefits with very few side effects, particularly in the case of tropical diseases.

Developing Countries↗
PubMed2005

Public-private partnership: from there to here.

Major changes in research and development (R&D) for drugs to treat tropical and neglected diseases have occurred in the past five years. Public-private partnerships for product development (PD PPPs) have emerged since rising drug development costs pushed pharmaceutical companies out of R&D for these diseases of the developing world and are now having an impact on the discovery and development of new medicines to treat them. PD PPPs can be an efficient model for bridging the translational research gap between basic research and clinical development by bringing together expertise from academia, the pharmaceutical industry and the public sector. Sustainability of funding is a serious problem. At present, one or two key philanthropic organisations provide a large proportion of the funding. Drug development typically takes 10 years and only 10 per cent of initial projects make it into the clinic. The partnerships need to widen their funding base and ensure that the funders understand the high level of attrition. Public-private partnerships have proved that they can move compounds quickly through the R&D pipeline. The challenge is to ensure that the products are delivered to the people who need them and to ensure that scientists in endemic countries are involved in the whole process.

Drug Industry↗
PubMed2004

Results of a hospital waste survey in private hospitals in Fars province, Iran.

Hospital waste is considered dangerous because it may possess pathogenic agents and can cause undesirable effects on human health and the environment. In Iran, neither rules have been compiled nor does exact information exist regarding hospital waste management. The survey presented in this article was carried out in all 15 private hospitals of Fars province (Iran) from the total numbers of 50 governmental and private hospitals located in this province, in order to determine the amount of different kinds of waste produced and the present situation of waste management. The results indicated that the waste generation rate is 4.45 kg/bed/day, which includes 1830 kg (71.44%) of domestic waste, 712 kg (27.8%) of infectious waste, and 19.6 kg (0.76%) of sharps. Segregation of the different types of waste is not carried out perfectly. Two (13.3%) of the hospitals use containers without lids for on-site transport of wastes. Nine (60%) of the hospitals are equipped with an incinerator and six of them (40%) have operational problems with the incinerators. In all hospitals municipal workers transport waste outside the hospital premises daily or at the most on alternative days. In the hospitals under study, there aren't any training courses about hospital waste management and the hazards associated with them. The training courses that are provided are either ineffective or unsuitable. Performing extensive studies all over the country, compiling and enacting rules, establishing standards and providing effective personnel training are the main challenges for the concerned authorities and specialists in this field.

Data Collection↗
PubMed2003

The difficult patient in private practice physiotherapy: a qualitative study.

This qualitative study utilised the nominal group technique to identify a typology of the difficult patient in private practice physiotherapy and to determine strategies physiotherapists use, and would like to improve, when dealing with such patients. The two areas physiotherapists found most difficult to manage were behavioural problems of patients and patient expectations. Few differences were evident regarding ranking of difficult patient attributes between the experienced (n = 19) and less experienced (n = 18) physiotherapists except for the categories of pain and diagnosed psychological problems. While less experienced physiotherapists ranked the pain category highly, experienced physiotherapists did not identify this category. Further, more experienced physiotherapists specifically distinguished between patients with diagnosed psychological problems and patients with psychosocial concerns, while less experienced physiotherapists did not, and placed both these issues into one category. To assist in their interaction with difficult patients, physiotherapists (n = 37) identified that communication skills and behaviour modification techniques were strategies that they would like to learn more about. The results of this qualitative study contribute to the evolving literature relating to physiotherapist-patient interactions and form a useful basis for educational programs directed at improving the therapeutic relationship in private practice physiotherapy.

Attitude of Health Personnel↗
PubMed2003

The physiotherapy experience in private practice: the patients' perspective.

The aim of this study was to identify the qualities of a "good" physiotherapist and to ascertain the characteristics of good and bad experiences in private practice physiotherapy from the patients' perspective. The nominal group technique was implemented with separate groups of patients (n = 26) and revealed that communication ability, professional behaviour and organisational ability, and characteristics of the service provided were the main qualities of a "good" physiotherapist. In particular, communication ability of the physiotherapist was ranked first or second in importance by all groups of patients. Good experiences in physiotherapy were most often attributed to effective communication by the physiotherapist, while bad experiences most often related to dissatisfaction with the service followed by poor physiotherapist communication. Based on the findings from this study, we suggest physiotherapists should actively seek to involve patients in their management. To do this effectively, physiotherapists would benefit from further training in communication skills to ensure that they can successfully adopt a patient-centred approach and to optimise the physiotherapist-patient interaction in private practice physiotherapy.

Adult↗
PubMedDate not supplied

Borderline personality disorder and bipolar II disorder in private practice depressed outpatients.

Bipolar II disorder (BDII) may be confused with borderline personality disorder (BPD) when it is cyclothymic between episodes. The aim of the present study was to determine the prevalence of BPD and to test whether BDII can be distinguished from BPD without difficulty in private practice mood disorder outpatients. Private practice was chosen because it is often the first or second line of treatment of mood disorders in Italy, and many "soft" patients can be found in this setting. Among 63 consecutive unipolar and 50 bipolar II major depressive episode (MDE) outpatients interviewed with the Structured Clinical Interviews for DSM-IV axis I/II disorders (SCIDs), the prevalence of BPD was 6.1% and was significantly higher in BDII patients (12% v. 1.5%). Overall, the rate of BPD diagnosis was very low. BDII was distinguished from BPD without difficulty by DSM-IV criteria. The results suggest that there may be a subgroup of BDII patients with a relatively stable course between episodes (or at least not so unstable as to suggest a BPD diagnosis or comorbidity) and a low comorbidity with BPD, in a setting closer to community patients than university settings. The "usual" BDII patient can be distinguished from the BPD patient.

Adult↗
PubMed1999

Public- and private-sector partnerships in contraceptive research and development: guiding principles.

The objective was to review and analyze practices of preferential pricing and royalties for products resulting from collaboration between the public and private sectors. A wide variety of practices and experience exist, and collaboration depends on the product being developed and its potential markets. Guiding principles in preferential pricing, royalty provisions, and long-term collaboration are presented that can be mutually beneficial to both the public and private sector.

Contraceptive Agents↗
PubMed1988

Private geriatric case management: current trends and future directions.

Private geriatric case management is a means of meeting the complex service needs of older persons who do not qualify for publicly funded programs or who seek services that the public sector does not provide. InterStudy surveyed 117 private case management firms and compiled a profile of service providers and their clients, types of services offered, fees charged, and other information. The study raises issues about access to and the quality of case management and other services for the elderly.

Aged↗
PubMed1996

Glaucoma care and conformance with preferred practice patterns. Examination of the private, community-based ophthalmologist.

BACKGROUND: Practice guidelines are becoming more prominent in the provision of medical care. A previous study demonstrated a high rate of conformance with recommended patterns of care for patients with open-angle glaucoma in an academic, public clinic setting. This study seeks to examine conformance within the private, community-based setting in which the vast majority of healthcare is delivered. METHODS: One-hundred ninety-three charts (average, 24 charts each from 8 different practices) of patients who received diagnoses for at least 2 years of open-angle glaucoma were evaluated retrospectively for conformance with recommendations from the American Academy of Ophthalmology's Preferred Practice Pattern (PPP) for primary open-angle glaucoma. The criteria were evaluated in three areas: (1) the performance of specified examination steps at the initial visit; (2) the performance of specified examination steps at follow-up; and (3) the time interval between follow-up visits. RESULTS: In 56.4% of patients who had stable moderate to severe glaucomatous damage, documentation of examination findings on the initial visit ranged from 39.4% for a pupil examination to 100% for intraocular pressure. At the initial visit, visual fields were obtained or scheduled in 90.2% of eyes, gonioscopy was performed in 51.3%, and the disc/nerve fiber layer status was noted in 97.9%. On follow-up, 44% of patients had documentation concerning the status of their glaucoma, but only 23.3% of patients had an optic nerve head drawing or photograph within 15 months of the most recent visit. In addition, the authors found that 37.8% of patient charts had neither an optic nerve head drawing nor a photograph documented after the initial visit. Finally, although 92.2% of patients with glaucoma were scheduled for follow-up within the time intervals recommended by the PPP, patients with uncontrolled or unstable glaucoma were the least likely to be followed up within PPP-recommended time intervals. CONCLUSIONS: Chart reviews from private, community-based ophthalmologists show that some initial examination steps such as gonioscopy and pupil examination are performed to widely varying degrees. While patients are generally likely to be scheduled for follow-up within PPP-recommended intervals, patients with unstable glaucoma are the least likely to be so scheduled. In addition, the visual appearance of the optic nerve is recorded for a relatively low percentage of patients. Additional data are needed from other geographic areas and other practice settings and for other patterns of care to more fully assess provider behavior relative to PPPs.

Community Medicine↗
PubMed2003

Moral hazard and adverse selection in Australian private hospitals: 1989-1990.

The Australian hospital system is characterized by the co-existence of private hospitals, where individuals pay for services and public hospitals, where services are free to all but delivered after a waiting time. The decision to purchase insurance for private hospital treatment depends on the trade-off between the price of treatment, waiting time, and the insurance premium. Clearly, the potential for adverse selection and moral hazard exists. When the endogeneity of the insurance decision is accounted for, the extent of moral hazard can substantially increase the expected length of a hospital stay by a factor of up to 3.

Adult↗
PubMed2000

Service quality in public and private hospitals in urban Bangladesh: a comparative study.

This study compared the quality of services provided by private and public hospitals in urban Bangladesh. Using twenty-four scale items, patient perceptions were sought on five aspects of service quality including responsiveness, assurance, communication, discipline and baksheesh. Because private hospitals are not subsidized, it was felt that the incentive structure would induce them to provide better services than public hospitals on the measures of service quality. This contention was largely supported. The results also indicated that both groups have room for improvement.

Bangladesh↗
PubMed2000

Public purchasing and private priorities for healthcare in New Zealand.

The 1993 Health and Disability Services Act heralded a range of structural reforms in the New Zealand health care system. Despite these reforms considerable resources being spent on convincing consumers of their merits, have failed to gain widespread public approval. This paper examines two key issues that have arisen during the reform process. These are the difficulties associated with trying to set priorities in ways which are effective and politically acceptable, and the relationship between the public and private sectors. Unacknowledged conflicts of interest have helped to undermine the priority setting process. The discussion suggests that it may be increasingly difficult for any government in future to determine the allocation of resources without taking private sector interests and rising public concern into account. It remains to be seen which of these factors is more powerful.

Contract Services↗
PubMed2000

Private psychiatric practice in an era of managed care.

Managed care is a given for private practice right now. It is important to develop a practice you can be proud of and be comfortable to work in by practicing ethically, with high standards for quality. Be persistent in expecting the same from the managed care companies, your colleagues, and your patients. Solid clinical and business principles are the backbone of private practice.

Attitude of Health Personnel↗