Larger private-sector role in health care needed now,think tank warns.

The Fraser Institute, a conservative think tank based in Vancouver, has called for the establishment of a parallel private health care sector to relieve pressure on the public system, encourage the development of medical technology, stimulate the economy and create jobs. The proposal includes establishment of competition by separating the roles of purchaser and provider of health care, and the creation of a medical premium account for each Canadian that would be funded by government but apportioned by the patient.     

Visions of our health care future: is a parallel private system the answer?

In this time of spending restraint, arguments for and against a two-tier medical system are common. Proponents say governments can no longer afford to supply all the health care we want and Canadians should have the right to purchase it, just as they purchases other services and commodities. Opponents fear that administrative costs will rise greatly if this happens, the best physicians will leave the public system and public support for medicare will erode. For this article, Charlotte Gray sought opinions on whether a parallel private system is a good option for Canadians to consider.     

Expectant Parents’ Understanding of the Implications and Management of Fever in the Neonate

Objective

We estimated the extent to which Canadian expectant parents would seek medical care in a febrile neonate (age 30 days or less). We also evaluated expectant parents’ knowledge of signs and symptoms of fever in a neonate, and explored the actions Canadian expectant parents would take to optimize the health of their child.

Methods

We conducted a cross-sectional survey of a sample of expectant parents from a large urban center in Canada. We recruited participants from waiting rooms in an obstetrical ultrasound clinic located in an urban tertiary care hospital in Montreal, Canada. We asked participants nine questions about fever in neonates including if, and how, they would seek care for their neonate if they suspected he/she were febrile.

Results

Among the 355 respondents, (response rate 87%) we found that 75% of parents reported that they would take their febrile neonate for immediate medical assessment, with nearly one fifth of the sample reporting that they would not seek medical care. We found no significant associations between the choice to seek medical care and expectant parents socio-demographic characteristics.

Conclusions

Despite universal access to high quality health care in Canada, our study highlights concerning gaps in the knowledge of the care of the febrile infant in one fifth of expectant parents. Physicians and health providers should strive to provide early education to expectant parents about how to recognize signs of fever in the neonate and how best to seek medical care. This may improve neonatal health outcomes in Canada.     

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.     

Integration of mental health into primary care in Kenya

Integration of mental health into primary care is essential in Kenya, where there are only 75 psychiatrists for 38 million population, of whom 21 are in the universities and 28 in private practice. A partnership between the Ministry of Health, the Kenya Psychiatric Association and the World Health Organization (WHO) Collaborating Centre, Institute of Psychiatry, Kings College London was funded by Nuffield Foundation to train 3,000 of the 5,000 primary health care staff in the public health system across Kenya, using a sustainable general health system approach. The content of training was closely aligned to the generic tasks of the health workers. The training delivery was integrated into the normal national training delivery system, and accompanied by capacity building courses for district and provincial level staff to encourage the inclusion of mental health in the district and provincial annual operational plans, and to promote the coordination and supervision of mental health services in primary care by district psychiatric nurses and district public health nurses. The project trained 41 trainers, who have so far trained 1671 primary care staff, achieving a mean change in knowledge score of 42% to 77%. Qualitative observations of subsequent clinical practice have demonstrated improvements in assessment, diagnosis, management, record keeping, medicine supply, intersectoral liaison and public education. Around 200 supervisors (psychiatrists, psychiatric nurses and district public health nurses) have also been trained. The project experience may be useful for other countries also wishing to conduct similar sustainable training and supervision programmes.     

Medicaid and the Mainstream: Reassessment in the Context of the Taxpayer Revolt

California''s Medicaid program—Medi-Cal—attempted to implement the ideal of mainstream medical care for the poor by giving program beneficiaries a “credit card” for use in the private health care marketplace. This exposed the program to the perverse economic incentives of the fee-for-service, costplus health care system, and contributed to a high rate of increase in program costs. Attempts to control costs have been equally perverse, resulting in low payment rates, the second-guessing of physician professional judgments, the probing of medical and fiscal records, and the use of computerized surveillance systems.Attempts to shift to the use of more efficient delivery systems have had small success. Attempts to attain cost containment through restructuring the Medi-Cal program have been rejected in the name of the mainstream ideal. Costs have continued to escalate, with annual increases as high as 20 percent in some years. Medi-Cal now costs $4 billion per year, the largest single program in California state government.The taxpayer revolt in California is creating a fiscal crisis that will force rethinking of the premises of publicly funded health care for the poor, and a restructuring of strategies for reaching that objective. In the short run, it appears that the issue may not be whether the indigent will have access to mainstream medical care, but whether they will have access to any medical care. In the longer run, the crisis should represent an opportunity for building a system of health care that can serve the financially disadvantaged at a cost tolerable to our society.     

Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review

Introduction

Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.

Methods and Findings

Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of “private sector” included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. “Competitive dynamics” for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.

Conclusions

Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients. Please see later in the article for the Editors'' Summary     

Is Private Health Care the Answer to the Health Problems of the World's Poor?

Background to the debate: The global burden of disease falls disproportionately upon the world''s low-income countries, which are often struggling with weak health systems. Both the public and private sector deliver health care in these countries, but the appropriate role for each of these sectors in health system strengthening remains controversial. This debate examines whether the private sector should step up its involvement in the health systems of low-income countries.     

Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level

Physical disorders are, compared to the general population, more prevalent in people with severe mental illness (SMI). Although this excess morbidity and mortality is largely due to modifiable lifestyle risk factors, the screening and assessment of physical health aspects remains poor, even in developed countries. Moreover, specific patient, provider, treatment and system factors act as barriers to the recognition and to the management of physical diseases in people with SMI. Psychiatrists can play a pivotal role in the improvement of the physical health of these patients by expanding their task from clinical psychiatric care to the monitoring and treatment of crucial physical parameters. At a system level, actions are not easy to realize, especially for developing countries. However, at an individual level, even simple and very basic monitoring and treatment actions, undertaken by the treating clinician, can already improve the problem of suboptimal medical care in this population. Adhering to monitoring and treatment guidelines will result in a substantial enhancement of physical health outcomes. Furthermore, psychiatrists can help educate and motivate people with SMI to address their suboptimal lifestyle, including smoking, unhealthy diet and lack of exercise. The adoption of the recommendations presented in this paper across health care systems throughout the world will contribute to a significant improvement in the medical and related psychiatric health outcomes of patients with SMI.     

Age as a Criterion for Setting Priorities in Health Care? A Survey of the German Public View

Although the German health care system has budget constraints similar to many other countries worldwide, a discussion on prioritization has not gained the attention of the public yet. To probe the acceptance of priority setting in medicine, a quantitative survey representative for the German public (n = 2031) was conducted. Here we focus on the results for age, a highly disputed criterion for prioritizing medical services. This criterion was investigated using different types of questionnaire items, from abstract age-related questions to health care scenarios, and discrete choice settings, all performed within the same sample. Several explanatory variables were included to account for differences in preference; in particular, interviewee''s own age but also his or her sex, socioeconomic status, and health status. There is little evidence that the German public accepts age as a criterion to prioritize health care services.     

Toronto centre hopes to cash in on growing demand for private health services

When the CMA held its 1996 annual meeting, part of the debate on the future of health care involved the "appropriate balance of the roles of the public and private sectors" in delivering health care. The King''s Health Centre in Toronto is now doing its own balancing act: providing publicly funded care to Canadians, and private care to non-Canadians and Canadians who can afford it. This article discusses some of the niche markets King''s is attempting to develop.     

Fatal hyperthermia associated with cocaine use.

Health insurance in the United States is failing patients and physicians alike. In this country 37 million uninsured face economic barriers to care, and the health of many suffers as a result. The "corporatization" of medical care threatens professional values with an unprecedented administrative and commercial intrusion into the daily practice of medicine. Competitive strategies have also failed their most ostensible goal--cost control. In contrast, Canada offers a model of a national health insurance plan that provides universal and comprehensive coverage, succeeds at restraining health care inflation, and does little to abrogate the clinical autonomy of physicians in private practice. I propose that American physicians relent in their historical opposition to national health insurance and participate in the development of a universal, public insurance plan responsive to the needs of both patients and physicians.     

THE ROLE OF GOVERNMENT IN MEDICINE

On the fundamental question of how far a government should be involved in health services, the author believes these things can appropriately be said: The government should continue to assume complete control over public health measures, and public health officials could well be permitted to invade medical services insofar as is necessary to achieve public health ends.To assist in the production of medical personnel, it is also fitting for the government to provide for increased teaching facilities, higher salaries for teachers in the medical field and scholarships for worthy students.In the area of insurance and prepayment plans, a really intelligent supervision of such devices, with the exercise of no more arbitrary governmental power than is now used by the various other regulatory commissions, is a suitable governmental function. The government''s buying policies for its wards, rather than providing direct medical services for them, should be encouraged. This would give the private practice of medicine a boost and would improve the quality of medical care. Government should encourage the regionalization of medical services with as much of the actual controls exercised at the local level as can be achieved. Private means should be utilized for the provision of these services and public means should be used for their payment when this is an obligation of the government.The problem of mass education in health matters should be tackled by government. It would be a fine thing if the medical profession and governmental agencies could agree upon delineation of their respective roles in the health field.Because further experimentation is needed before the ideal solution is found, both government and organized medicine should encourage the exploration of new approaches.     

Healthy firms: constraints to growth among private health sector facilities in Ghana and Kenya

Background

Health outcomes in developing countries continue to lag the developed world, and many countries are not on target to meet the Millennium Development Goals. The private health sector provides much of the care in many developing countries (e.g., approximately 50 percent in Sub-Saharan Africa), but private providers are often poorly integrated into the health system. Efforts to improve health systems performance will need to include the private sector and increase its contributions to national health goals. However, the literature on constraints private health care providers face is limited.

Methodology/Principal Findings

We analyze data from a survey of private health facilities in Kenya and Ghana to evaluate growth constraints facing private providers. A significant portion of facilities (Ghana: 62 percent; Kenya: 40 percent) report limited access to finance as the most significant barrier they face; only a small minority of facilities report using formal credit institutions to finance day to day operations (Ghana: 6 percent; Kenya: 11 percent). Other important barriers include corruption, crime, limited demand for goods and services, and poor public infrastructure. Most facilities have paper-based rather than electronic systems for patient records (Ghana: 30 percent; Kenya: 22 percent), accounting (Ghana: 45 percent; Kenya: 27 percent), and inventory control (Ghana: 41 percent; Kenya: 24 percent). A majority of clinics in both countries report undertaking activities to improve provider skills and to monitor the level and quality of care they provide. However, only a minority of pharmacies report undertaking such activities.

Conclusions/Significance

The results suggest that improved access to finance and improving business processes especially among pharmacies would support improved contributions by private health facilities. These strategies might be complementary if providers are more able to take advantage of increased access to finance when they have the business processes in place for operating a successful business and health facility.     

Disease intervention specialists as a resource in a public health emergency

With the current shortage of qualified staff at state and local public health departments, a flexible public health workforce could fill critical gaps in staffing. Disease intervention specialists (DISs) are public health outreach workers who are responsible for finding and counseling people with sexually transmitted diseases and their contacts. DIS skills and job duties parallel those that would be needed to respond quickly and efficiently to urgent public health problems, including bioterrorism. Including DISs in public health preparedness planning could be a practical way of providing surge capacity for departments of public health. In many states, DISs are already being used for functions that fall outside their traditional duties. However, planning and DIS training are essential for effective utilization of DIS skills in a public health emergency. North Carolina has included DISs in their bioterrorism response plans and currently deploys them on an as-needed basis for nonroutine activities.     

Attitudes to publicly funded obesity treatment and prevention

The aim of this study was to investigate the Danish public's support for publicly funded obesity treatment and prevention. It was also examined whether levels of support could be explained by dislike of obese people and/or the belief that those who are obese are personally responsible for their condition. A representative survey of members of the Danish public (N = 1,141) was conducted using a web-based questionnaire. The survey was designed to assess attitudes to public funding for obesity-related health care, and to investigate the impact, on those attitudes, of dislike of obese people, the perceived controllability of obesity, self-reported BMI, and additional attitudinal and socio-demographic characteristics. Public funding of some obesity treatments, such as weight-loss surgery, attracted only limited public support. A majority of the Danish public did support "softer" treatment interventions and preventive initiatives. Attitudes to the treatment of obesity were clearly best predicted by the belief that individuals are personally responsible for their own obesity. Dislike of obese persons had no direct effect on the preference for collective treatment initiatives and only a small effect on support for publicly funded obesity prevention. The high level of disapproval for publicly funded obesity treatment should be cause for concern for decision makers aiming to ensure equal access to health care. Since it is the belief that obese people are personally responsible which explains this disapproval, strategies for challenging public opinion on this issue are discussed.     

Why not private health insurance? 2. Actuarial principles meet provider dreams

What do insurers and employers feel about proposals to expand Canadian health care financing through private insurance, in either a parallel stream or a supplementary tier? The authors conducted 10 semistructured, open-ended interviews in the autumn and early winter of 1996 with representatives of the insurance industry and benefits managers working with large employers; respondents were identified using a snowball sampling technique. The respondents felt that proposals for parallel private plans within a competitive market are incompatible with insurance principles, as long as a well-functioning and relatively comprehensive public system continues to exist; the maintenance of a strong public system was both socially and economically desirable. With the exception of serving the niche market for the private management of return-to-work strategies, respondents showed little interest in providing parallel coverage. They were receptive to a larger role for supplementary insurance but cautioned that they are not willing to cover all delisted services. As business executives they stated that they are willing to insure only services and clients that will be profitable.