What motivates physicians to propose private services in a mixed private-public healthcare system? A mixed methods study

Background Implementation of private elements, including private insurances, in public healthcare system is now common in many countries, and its impacts have been well studied. Little, however, is known about the motives leading physicians, major role players in the system, to promote the usage of private services. The aim of this study was to explore the various motives leading physicians within public systems to propose private services to their patients, while examining the possible associations to their specialty and level of commitment. Methods A total of 197 physicians from specialisms loaded more to private/public sectors participated in a cross-sectional telephone survey regarding their attitudes on their practices, private insurances, access to healthcare, and job satisfaction. The association between the likert scale questions to their recommendation to purchase private insurance, and the commitment they felt towards patients were analyzed using Generalized Estimating Equations (GEE) as well as logistic regression models. Results Our findings suggest physicians engaged in dual practice are less likely to promote private insurances among their patients if they are satisfied with their public job (OR = 0.92, 95%CI 0.89,0.94). Physicians perceived private insurances as beneficial for patients, were found likely to promote them (OR = 1.65, %95CI 1.16, 2.35). The commitment physicians felt toward patients who paid out-of-pocket money was associated to their sense of being trusted and valued (OR = 1.99, 95%CI 1.33, 2.88; OR = 1.5, 95%CI 1.05, 2.13 respectively). Conclusion This study suggests a deeper understanding of physicians’ daily experience of the private-public mix and it’s consequences, and could provide a platform for future studies. Further studies on physician’s role in health privatization processes are needed, and could aid policymakers in their efforts to strengthen healthcare systems around the world.

Within the Circle of Care: the Patient's Lived Experience of Receiving Palliative Care

<p>I am a Registered Comprehensive Nurse with dual practice interests in the care of terminally ill people, and in quality improvement. This research study originates from my experience of working in a hospice as a clinical nurse then as a quality improvement co-ordinator in the early 1990s. At this time, quality improvement in the health services was relatively new, and there was no locally published research on quality improvement in palliative care. World wide there was a developing body of palliative care quality improvement literature (Higginson 1989, 1993, 1995); however there had been little research undertaken which reflected the patients' perception of the palliative care experience. As a result of my work experience came the quest to find out directly from patients, the aspects of care which they considered valuable. I chose to use the descriptive-phenomenological methodology particularly utilising van Manen's (1990) phenomenological method. This methodology allows the participants' experience to stand apart from existing health professional defined palliative care knowledge, yet provides a way for this participant knowledge to complement and augment it. This descriptive-phenomenological study describes six persons' experience of care within a palliative care setting, and discusses the possible significance that this may have for the practice of palliative care. The participants had at least two care experiences within this setting and were interviewed on one occasion shortly after their discharge, within their own homes. I invited the participants to talk about their care experiences. The anecdotes which the participants relayed, when reflected on, revealed both a pattern of storytelling as well as individual components of care. These components or elements of the care experience as well as informing each other, created a representation, a schematic description of their experience. The representation 'The circle of care', is orientated around the central component of 'identity', with the encircling valued components of care being: 'keeping control', 'being safe', 'chosen isolation', 'mortality awareness', 'relaxation and relinquishment', 'caring qualities', 'being watched' and 'humour'. The circle of 'palliative care philosophy' contained these components, finally being enclosed by an outer circle of the 'spiritual\aesthetic qualities of the environment of care'. The reality of people receiving palliative care is characterised by a number of supportive traditional and non-traditional aspects of caring. Although some characteristics have been described within general health and palliative care literature, some appear to have been generated by these particular participants as part their reality. The selected methodological approach and results limit the study to the context in which it was conducted. However the study suggests that patients are valued informants, and that they are able to augment existing palliative care knowledge. Ideally their input should be sought within the current systems of evaluating existing care and in the creation of new models of care.</p>

Within the Circle of Care: the Patient's Lived Experience of Receiving Palliative Care

<p>I am a Registered Comprehensive Nurse with dual practice interests in the care of terminally ill people, and in quality improvement. This research study originates from my experience of working in a hospice as a clinical nurse then as a quality improvement co-ordinator in the early 1990s. At this time, quality improvement in the health services was relatively new, and there was no locally published research on quality improvement in palliative care. World wide there was a developing body of palliative care quality improvement literature (Higginson 1989, 1993, 1995); however there had been little research undertaken which reflected the patients' perception of the palliative care experience. As a result of my work experience came the quest to find out directly from patients, the aspects of care which they considered valuable. I chose to use the descriptive-phenomenological methodology particularly utilising van Manen's (1990) phenomenological method. This methodology allows the participants' experience to stand apart from existing health professional defined palliative care knowledge, yet provides a way for this participant knowledge to complement and augment it. This descriptive-phenomenological study describes six persons' experience of care within a palliative care setting, and discusses the possible significance that this may have for the practice of palliative care. The participants had at least two care experiences within this setting and were interviewed on one occasion shortly after their discharge, within their own homes. I invited the participants to talk about their care experiences. The anecdotes which the participants relayed, when reflected on, revealed both a pattern of storytelling as well as individual components of care. These components or elements of the care experience as well as informing each other, created a representation, a schematic description of their experience. The representation 'The circle of care', is orientated around the central component of 'identity', with the encircling valued components of care being: 'keeping control', 'being safe', 'chosen isolation', 'mortality awareness', 'relaxation and relinquishment', 'caring qualities', 'being watched' and 'humour'. The circle of 'palliative care philosophy' contained these components, finally being enclosed by an outer circle of the 'spiritual\aesthetic qualities of the environment of care'. The reality of people receiving palliative care is characterised by a number of supportive traditional and non-traditional aspects of caring. Although some characteristics have been described within general health and palliative care literature, some appear to have been generated by these particular participants as part their reality. The selected methodological approach and results limit the study to the context in which it was conducted. However the study suggests that patients are valued informants, and that they are able to augment existing palliative care knowledge. Ideally their input should be sought within the current systems of evaluating existing care and in the creation of new models of care.</p>

Stakeholders’ Perspectives on the Unmet Needs and Health Priorities of the Urban Poor in South-East Nigeria

Relatively little is known about readiness of urban health systems to address health needs of the poor. This study explored stakeholders’ perception of health needs and strategies for improving health of the urban poor using qualitative analysis. Focus group discussions (n = 5) were held with 26 stakeholders drawn from two Nigerian states during a workshop. Urban areas are characterised by double burden of diseases. Poor housing, lack of basic amenities, poverty, and poor access to information are determinants of health of the urban poor. Shortage of health workers, stock-out of medicines, high cost of care, lack of clinical practice guidelines, and dual practice constrain access to primary health services. An overarching strategy, that prioritises community-driven urban planning, health-in-all policies, structured linkages between informal and formal providers, financial protection schemes, and strengthening of primary health care system, is required to address health needs of the urban poor.

Implications of Dual Practice on Cataract Surgery Waiting Time and Rescheduling: The Case of Malaysia

Background: Dual practice was implemented in selected Ministry of Health Malaysia hospitals to reduce brain drain and provide an alternative for patients willing to pay higher user fees to seek prompt treatment from the specialist of their choice. This study aimed to assess the implications of dual practice on waiting time and rescheduling for cataract surgery. Methods: A retrospective study was conducted in a referral hospital. Inpatient medical records of patients who underwent cataract procedures were used to study the waiting times to surgery and rescheduling between private and public groups. Results: Private patients had a considerably shorter waiting time for cataract surgery, seven times shorter compared to public patients where all surgeries were conducted after hours on weekdays or weekends. Additionally, 14.9% of public patients experienced surgery rescheduling, while all private patients had their surgeries as planned. The main reason for surgery rescheduling was the medical factor, primarily due to uncontrolled blood pressure and upper respiratory tract infection. Conclusion: Private service provision utilizing out-of-office hours slots for cataract surgery optimizes public hospital resources, allowing shorter waiting times and providing an alternative to meet healthcare needs.

DELINEATINGACCESS TO SPECIALTY HEALTHCARE IN ZIMBABWE A CROSS-SECTIONAL STUDY TO INFORMEVIDENCE-BASED PUBLIC HEALTH POLICY AND PRACTICE

The study investigated the determinants of access and utilization of specialty healthcare services in the case of public referral hospitals in Zimbabwe using the period post-independence in 1980s to 2018. This becomes an exciting period for the study as it presents the rise and fall of Zimbabwe’s healthcare system. Although there are many specialists offering specialty healthcare, the study limited its focus on specialty care physicians operating at public health facilities. The study objectives were to identify the socio-economic and health behavioural determinants that could influence access to and utilization of specialty healthcare amongst different groupings in Zimbabwe. The study specifically examined the influence of household income, insurance, health information/ education, distance to the nearest health centre, waiting time and dual practice as a variable of interest on access to specialty care. The study utilized cross-sectional household data collected through a survey from April to October 2019. Out of the 40 selected districts from a cluster of 63 existing administrative health districts, 1000 households were randomly selected using one stage cluster sampling (probability sampling design). The study used the Logistic regression model to identify the determinants of access to and utilisation of specialty healthcare based on 653 households that had reported sickness of a member within the last twelve months before the survey. The study tested the hypotheses that dual practice does not affect the supply capacity at public hospitals hence does not reduce access and utilisation of specialty healthcare household income does not increase the demand for specialized healthcare services and that the distance to the nearest health facility does not reduce the probability of seeking of specialty healthcare services. The Logistic regression results revealed that distance to the nearest health care facility, household income, health insurance coverage, presence of dual practice and waiting time all had a significant statistical relationship with access and utilization (demand) for specialty healthcare at public health institutions. However, the study found out that health information had negative effect though an insignificant variable. Distance to the nearest health facility and waiting time was found to negatively affect access (demand) to specialty healthcare whereas household income, dual practice and insurance coverage were found to positively influence access and utilization of specialty healthcare at public health institutions. The study established that, as there is an increase in income and insurance coverage, access and utilization of specialty care also increased. More households in Zimbabwe (71%) are not medically insured. The study found that the provision of specialty healthcare services is too centralized thereby patients are compelled to travel long distancesto metropolitan facilities where specialty health services are more concentrated. The study further established that dual practice affects the supply capacity in public hospitals. The constraining arrangement of management and teaching services at main teaching hospitals affects the supply of specialty services. Households tend to wait longer to consult specialists at public hospitals due to poorly regulated dual practice that induces long waiting times. Given the study findings, the study recommends health policy planners to adopt a balanced centralized and decentralized modelon access to specialty care, differentiating higher and lower tier specialty care facilities to address the geographic accessibility and availability dimensions and revisiting management of training and structuring of specialty teaching services. Other major recommendations of the study include the review of supply-side policies used to enhance access to specialty healthcare services. The policies may target at implementing a public sector ‘National Health Insurance Fund’, driven by the government of Zimbabwe offering realistic, acceptable and affordable premiums for vulnerable groups and expanding the scope of participation in developing the policy regulating dual practice. The study also recommends the creation of Special Economic Zones (SEZ) for Specialty health riding on the existing Government framework on SEZs. The adoption of Strategic Specialty care Partnerships (SSCPs) can enhance access and institutional capacities in dealing with the expensive response to Non Communicable Diseases, which are the main drivers for households to seek specialty care. Zimbabwe through its national health authority needs to ‘Reframe the Health Agenda’ on specialty care thus initiate a national health action plan that will continue to drive to evidence-based health policy and practice.

The author’s pedagogical model of health’s formation among russian judokas of preschool age

This article examines the scientific problem of health’s formation among Russian (non-oriented) judokas of preschool age through their early immersion in judo practice. The solution to this scientific problem is extremely important in the context of the necessity to form a special creative kids’ ability to “adapt as quickly as possible to a partner / changing situation, anticipating the result, with minimal costs and maximum achievement of the chosen goal”, which determines the effectiveness of mastering and practicing judo. Complex analysis of the judo’s phenomenon in the context of main types and components of health allows us to consider it in four dimensions: social (level of communication), spiritual (level of consciousness), soulful (level of subconscious and unconscious) and physical (level of corporeality). The application of the method of theoretical modeling made it possible to propose the author’s pedagogical model of judokas’ health formation through the dual practice of judo: judo as a life principle (the judo’s practice number one) and judo as the eastern system of formation of a person’s physical culture (the judo’s practice number two). The author’s pedagogical model of health’s formation among Russian judokas of preschool age is based on the implementation of the judo’s practice number two. The effectiveness of this author’s pedagogical model has been confirmed experimentally.

Growth and welfare in mixed health system financing with physician dual practice in a developing economy: a case of Indonesia

Based on Indonesia’s hybrid BPJS Kesehatan health system, we analyze for welfare-optimal government financing strategy in an economy with a mixed health system using an endogenous growth framework with physician dual practice. We find the model solution to produce two vastly different regimes in terms of policy implications: a “high” public-sector congestion regime as in the benchmark case of Indonesia, and a “low” public-sector congestion, high capacity regime. In the former, welfare-optimal health financing strategy appears to be promoting private health service. In contrast, in the low-congestion, high capacity regime, a welfare-optimal strategy is to do the opposite of increasing government physician wage at the expense of private health subsidy. These results highlight the importance of developing a benchmarking system that measures the actual degree of congestion faced by the public health service in a developing economy, as it ultimately would influence the optimal health financing strategy to be pursued.