tag:theconversation.com,2011:/au/topics/private-healthcare-14340/articlesprivate healthcare – The Conversation2023-05-30T05:16:35Ztag:theconversation.com,2011:article/2064912023-05-30T05:16:35Z2023-05-30T05:16:35ZThe real cost of New Zealand’s two-tier health system: why going private doesn’t relieve pressure on public hospitals<figure><img src="https://images.theconversation.com/files/528947/original/file-20230529-24-y696dn.jpg?ixlib=rb-1.1.0&rect=76%2C728%2C4981%2C2674&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>Ethicists argue that healthcare is special. Unlike other consumer goods, its availability and accessibility should be based on need rather than ability to pay.</p>
<p>In New Zealand, however, our tolerance of a two-tier health system – in which some services are only available for a price – suggests a degree of moral ambivalence. </p>
<p>Take, for instance, the recent Health and Disability Commissioner <a href="https://www.hdc.org.nz/media/6402/22hdc01310.pdf">report</a> detailing inadequacies in cancer treatment and management in southern parts of New Zealand. Alongside cases of patients seeking urgent cancer treatment in the <a href="https://www.odt.co.nz/news/dunedin/health/healthcare-delays-push-cancer-patient-private">private sector</a>, it raises questions of justice about our two-tier health system.</p>
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<p>Many seem to accept the argument that a two-tier public-private health system is not morally problematic, given most essential health services remain free to all. Some might go further and argue justice demands a two-tier system because health is only one public good the state is obliged to provide. Limiting non-essential healthcare services ensures it can meet those obligations. </p>
<p>The second private tier protects the liberty of those who want and can afford to purchase those services, while the first public tier focuses on meeting everyone’s needs to a sufficient level.</p>
<p>But the justice argument supports this conclusion only if the services and benefits provided in the first tier meet that threshold of sufficiency. Where exactly this threshold lies has been the subject of perennial debate. </p>
<h2>Eroding the public system</h2>
<p>We might start with the idea that a sufficient level of healthcare includes “<a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/769663">vital goods and services essential to human flourishing</a>”. </p>
<p>While this excludes some services (high-cost treatments with uncertain benefits), it demands more than what the public sector is currently providing to New Zealanders. It should include (at least) more comprehensive and universal access to primary and oral healthcare and timely access to cancer treatment.</p>
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<p>Our willingness to accept a second tier of healthcare accessible only to those who can pay depends on the sufficiency of the first tier. The worse the services in the first tier, the weaker the justification for the second tier.</p>
<p>Many also seem to accept the argument that the private sector plays an important, possibly even altruistic, role in supporting the public sector. A provider at a new private clinic in Dunedin recently <a href="https://www.odt.co.nz/news/dunedin/health/skipping-queue-placing-trust-somewhere-new">stated</a>:</p>
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<p>We’re proud to back up the public health system by providing an alternative service that will take some of the pressure off the public system.</p>
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<p>Patients are susceptible to the idea that by paying for private treatment they are “freeing up a bed” for someone in the public sector.</p>
<p>This argument is misleading at best. When the public system isn’t adequately resourced to meet the need, patients who receive their care privately do not have a bed or a spot to give up. The lack of a spot is often what drives them to the private system in the first place. </p>
<p>On the contrary, the proliferation of private-sector facilities and policies that favour this proliferation may either implicitly or explicitly aim to deplete the public sector. </p>
<p>Following the principle that every private bed is one the state does not need to provide, private beds don’t free up public beds, they replace them.</p>
<p>We should not be under any illusion that private insurance and private healthcare are altruistic in relieving pressure on the public system. They profit from failures of the public system to meet current needs and patients’ desperation to receive timely treatment.</p>
<h2>Eroding solidarity</h2>
<p>The Health and Disability Commissioner’s report on cancer treatment in the southern region highlights demonstrable harms for patients who did not receive timely treatment in the public system. In a particularly stark <a href="https://www.odt.co.nz/news/dunedin/health/public-private-health-divide-decides-brothers%E2%80%99-fate">recent case</a>, brothers who received cancer treatment in the public and private system respectively experienced tragically different outcomes. </p>
<p>Examples like this show a growing gap between the services available in the private and public tiers of our health system. This gap threatens social cohesion and solidarity. </p>
<p>When the worse-off are required to accept services below reasonable expectations of routine care (and the demonstrable harms that result), individuals are no longer in the same boat. The better-off live in a world of social goods and privileges inaccessible to the worse-off. </p>
<p>Why we accept this in health and not other sectors is an important question. It is hard to imagine school teachers only taking bookings months out to see parents seeking help for their troubled children, or denying entry to public schools due to limited capacity. </p>
<p>It is also doubtful we would accept teachers setting up private classes and consultation times to provide a timely service to those who can pay. </p>
<h2>Entrenched inequities</h2>
<p>The commodification of healthcare was built into the New Zealand system from the outset, with medical professionals demanding the freedom to charge fees for their services. The results are <a href="https://assets-global.website-files.com/5e332a62c703f653182faf47/5e332a62c703f6d08f2fdabe_content.pdf">evident in many of our health statistics</a> that reflect entrenched health inequities, particularly between Māori and non-Māori New Zealanders. </p>
<p>While we are likely stuck with a two-tier system for the foreseeable future, it can and should be made more just by ensuring all “vital goods and services” are securely provided in the public sector.</p>
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Read more:
<a href="https://theconversation.com/new-zealands-health-restructure-is-doomed-to-fall-short-unless-its-funding-model-is-tackled-first-179935">New Zealand's health restructure is doomed to fall short unless its funding model is tackled first</a>
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<p>Health is special. It preserves a range of opportunities people need to live flourishing lives. We should demand a health system that is committed to preserving those opportunities for everyone. </p>
<p>We need our political leaders to tell us whether they stand with us in support of this goal and indicate their commitment to universal healthcare. If so, we need them to acknowledge this can only be achieved with some fundamental shifts in how we think about the public-private divide.</p><img src="https://counter.theconversation.com/content/206491/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robin Gauld has received funding from the Health Research Council of New Zealand. He serves on the Board of Directors of Business South.</span></em></p><p class="fine-print"><em><span>Elizabeth Fenton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The argument that private healthcare relieves pressure on the public system is misleading. Private care profits from failures of the public system and patients’ desperation for timely treatment.Elizabeth Fenton, Lecturer in Bioethics, University of OtagoRobin Gauld, Professor; Co-Director, Centre for Health Systems and Technology, University of OtagoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2004272023-03-01T19:15:03Z2023-03-01T19:15:03ZFirst Nations are using ‘creative disruption’ to foster economic growth in their communities<figure><img src="https://images.theconversation.com/files/512515/original/file-20230227-2379-atkjkh.JPG?ixlib=rb-1.1.0&rect=194%2C389%2C6149%2C4057&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Prime Minister Justin Trudeau and Squamish Nation councillor Khelsilem hold a ceremonial paddle after a groundbreaking ceremony at the First Nation's Sen̓áḵw housing development site in Vancouver in September 2022.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span></figcaption></figure><p>First Nations have been resisting the <a href="https://doi.org/10.1177/2158244019879137">historic and ongoing impacts of Canada’s extractive economy</a> on their communities by exercising <a href="https://www.rcaanc-cirnac.gc.ca/eng/1100100032275/1529354547314">their right to self-governance</a> and taking control of their economic futures.</p>
<p>Creative disruption stands in contrast to <a href="https://www.econlib.org/library/Enc/bios/Schumpeter.html">creative <em>destruction</em></a>, a term coined by Austrian political economist Joseph Schumpeter. Schumpeter argued that capitalism causes old ideas and technology to quickly become obsolete through the process of innovation. In the pursuit of profit, capitalism ruthlessly and relentlessly eliminates old ideas and installs new ones.</p>
<p>Creative disruption, on the other hand, aims to make space for new ideas by forcing the old ways to adapt and adopt. First Nations communities are doing this in a number of ways.</p>
<p>As an academic with a background in urban land economics, I have studied how First Nations are using creative disruption to shape businesses, urban communities and the health-care system in Canada.</p>
<h2>Sen̓áḵw development project</h2>
<p>One of the ironies of modern Indigenous land law is how the reserve system defined by the Indian Act, originally <a href="https://indigenousfoundations.arts.ubc.ca/the_indian_act">designed to assimilate Indigenous nations and communities into mainstream Canadian culture</a>, has morphed into a strategic asset for First Nations.</p>
<p>As author Bob Joseph notes in <a href="https://www.cbc.ca/books/21-things-you-may-not-know-about-the-indian-act-1.4635204"><em>21 Things You May Not Know About the Indian Act</em></a>, the Squamish Nation lost 14 acres (about 0.05 square kilometres) of their territory in Vancouver to a lumber company through expropriation in 1904.</p>
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<img alt="A man in a suit speaks from behind a podium that says 'Building More Homes' on the front of it. In the background a group of people wearing fluorescent vests and hard hats stand in front of an excavator." src="https://images.theconversation.com/files/512516/original/file-20230227-194-6o080d.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/512516/original/file-20230227-194-6o080d.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/512516/original/file-20230227-194-6o080d.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/512516/original/file-20230227-194-6o080d.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/512516/original/file-20230227-194-6o080d.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/512516/original/file-20230227-194-6o080d.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/512516/original/file-20230227-194-6o080d.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Prime Minister Justin Trudeau speaks during an announcement and groundbreaking ceremony at the Squamish Nation’s Sen̓áḵw housing development site in Vancouver in September 2022.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
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<p>After a century of litigation, the <a href="https://www.cbc.ca/news/canada/british-columbia/little-known-history-of-squamish-nation-land-in-vancouver-1.5104584">Squamish Nation recovered some of the lost land</a> and <a href="https://globalnews.ca/news/9109033/squamish-nation-breaks-ground-housing-development/">is now in the process of building Sen̓áḵw</a>, a massive economic development project in Kits Point, Vancouver.</p>
<p>Sen̓áḵw is the largest Indigenous-led housing retail development in Canadian history and will add much-needed housing supply <a href="https://theconversation.com/new-study-reveals-intensified-housing-inequality-in-canada-from-1981-to-2016-173633">to a market that has become unaffordable</a> for most. The development plans to build <a href="https://www.theglobeandmail.com/canada/british-columbia/article-squamish-nations-planned-development-on-reserve-land-in-vancouver/">11 towers and 6,000 housing units</a>.</p>
<h2>Naawi-Oodena urban reserve</h2>
<p>A second example of creative disruption is the creation of the <a href="https://www.aptnnews.ca/national-news/naaawi-oodena-now-official-urban-reserve-in-winnipeg/">Naawi-Oodena urban reserve</a> in Winnipeg. It’s <a href="https://www.cbc.ca/news/canada/manitoba/naawi-oodena-repatriation-winnipeg-largest-urban-reserve-1.6691359">the largest urban reserve in Canada</a>, covering 64 hectares. </p>
<p>Naawi-Oodena was officially established after the land the reserve sits on — the former Kapyong Barracks — was recently repatriated to <a href="https://treaty1.ca/treaty-one-nation/">the seven Treaty One First Nations</a>.</p>
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<a href="https://theconversation.com/urban-reserves-are-tests-of-reconciliation-114472">Urban reserves are tests of reconciliation</a>
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<p>Treaty One Nation <a href="https://www.cbc.ca/news/canada/manitoba/first-nations-file-lawsuit-over-kapyong-land-1.695601">fought to have the land returned to them</a> under the provisions of the <a href="http://www.tlec.ca/framework-agreement/">Treaty Land Entitlement Framework Agreement</a> after the Canadian government tried to transfer the land to a Crown corporation years ago.</p>
<p>After a prolonged legal process, a judge ruled the <a href="https://www.cbc.ca/news/canada/manitoba/first-nations-not-consulted-on-kapyong-barracks-sale-court-rules-1.3192485">federal government failed to adequately consult with Treaty One Nation</a> and the land transfer was ruled illegitimate in 2015.</p>
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<p>An incorporated consortium run by the Treaty One Nation, called <a href="https://lpband.ca/treaty-one-development-corporation/">the Treaty One Development Corporation</a>, will oversee developments on Naawi-Oodena.</p>
<p>As a self-governing nation, Treaty One will set its own land management policies, potentially in contrast to the zoning and building codes of Winnipeg. In reality, it’s likely to gently push or disrupt urban development, rather than outright destroy current practices since its goal is to attract tenants, the majority of which will be non-Indigenous.</p>
<h2>First Nations health care</h2>
<p>First Nations entrepreneurs are also seeking out ways to revolutionize the Canadian health-care system. Enoch Cree Nation in Alberta entered into an agreement with contractors to <a href="https://www.cbc.ca/news/canada/edmonton/private-orthopedic-surgical-facility-coming-to-enoch-cree-nation-next-year-1.6474534">create a private health clinic</a> offering simple hip and knee surgeries. </p>
<p>The provincial government will fund the procedures through medicare and publicly funded hospitals will still handle more complicated surgeries. </p>
<p>Enoch Cree Nation joins a growing number of private health clinics in Canada forming public-private partnerships. They are not the first First Nation to get involved with health care, either. </p>
<p>In 2012, Westbank First Nation <a href="https://www.cbc.ca/news/canada/british-columbia/b-c-first-nation-plans-private-hospital-1.1298463">announced a plan to build a private, for-profit hospital</a>. Some constitutional experts <a href="https://www.cbc.ca/news/canada/british-columbia/westbank-first-nation-hospital-likely-unconstitutional-says-expert-1.1288670">warned that Westbank First Nation was violating the Canada Health Act</a>, but <a href="https://infotel.ca/newsitem/westbank-first-nations-private-hospital-still-on-shaky-legal-ground/it22697">the nation responded by arguing</a> that, as a self-governing nation, it was not bound by federal laws.</p>
<p>Enoch Cree Nation’s private clinic will face other challenges. While COVID-19 has shaken the faith Canadians have in our health-care system, and <a href="https://globalnews.ca/news/9458260/health-care-private-options-majority-canadians-support-poll">receptivity to private health care may be growing</a>, the affinity for public health care remains strong.</p>
<h2>Legal redress</h2>
<p>First Nations have also become creative disrupters by pursuing legal redress for past injustices. The courts have reached back through treaties all the way back to <a href="https://indigenousfoundations.arts.ubc.ca/royal_proclamation_1763/">the Royal Proclamation of 1763</a> to widen Canada’s constitution beyond the formal acts to include treaties with First Nations.</p>
<p>Institutional changes supporting disruption include <a href="https://laws.justice.gc.ca/eng/const/Const_index.html">Article 35 of the 1982 Constitution Act</a> that recognizes the “existing aboriginal and treaty rights of the aboriginal peoples of Canada.” This clause is widely interpreted as creating a nation-to-nation relationship between First Nations and Canada.</p>
<p>Equally important for commercial ventures is <a href="https://laws-lois.justice.gc.ca/eng/acts/i-5/">Article 87 of the Indian Act</a> which exempts First Nations land from taxation by any order of government. This means an urban reserve does not pay property tax to a municipality.</p>
<p>Despite <a href="https://www.thestar.com/news/canada/2021/02/06/bob-joseph-why-the-indian-act-must-go-and-canada-will-be-better-for-it.html">criticism of the Indian Act by authors like Joseph</a>, Article 87 offers a major fiscal benefit for First Nations individuals and businesses on reserve. Although a complex area of law, this tax exemption is an important reason why First Nations may prefer to add land to existing reserves or to create new reserves, rather than owning land conventionally like corporations.</p>
<h2>Furthering reconciliation</h2>
<p>Despite some First Nations regaining rights and titles to their lands, Indigenous communities in Canada still <a href="https://www.ourcommons.ca/Content/Committee/441/INAN/Reports/RP11714230/inanrp02/inanrp02-e.pdf">face many barriers to economic participation</a>. By engaging in the examples of creative disruption here, First Nations are working toward economic prosperity for their communities and, in the process, are also working toward reconciliation.</p>
<p>The <a href="https://www.un.org/development/desa/indigenouspeoples/wp-content/uploads/sites/19/2018/11/UNDRIP_E_web.pdf">United Nations Declaration on the Rights of Indigenous Peoples</a> — <a href="https://www2.gov.bc.ca/assets/gov/british-columbians-our-governments/indigenous-people/aboriginal-peoples-documents/calls_to_action_english2.pdf">the framework for reconciliation according to the Truth and Reconciliation Commission of Canada</a> — states Indigenous people have the right to pursue their own means of economic development. By starting their own entrepreneurial and developmental projects, First Nations are engaging in their inherent “right to maintain and develop their political, economic and social systems or institutions.”</p>
<p>Reconciliation also works best when all parties involved benefit from changes. These examples of creative disruption will benefit non-Indigenous Canadians as well as Indigenous people by increasing the housing supply in Vancouver and Winnipeg, bringing remote First Nations into the economic orbit of cities and offering increased health treatment options.</p><img src="https://counter.theconversation.com/content/200427/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gregory C Mason receives funding from The University of Manitoba and the Thorlakson Family Foundation Fund (Health related research).
</span></em></p>By starting their own entrepreneurial and developmental projects, First Nations are working toward economic prosperity for their communities and furthering reconciliation.Gregory C Mason, Associate Professor of Economics, University of ManitobaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1484212020-10-22T18:56:53Z2020-10-22T18:56:53ZWhy equal health access and outcomes should be a priority for Ardern’s new government<figure><img src="https://images.theconversation.com/files/364889/original/file-20201022-14-m2otak.jpg?ixlib=rb-1.1.0&rect=206%2C339%2C4714%2C2914&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock/ChameleonsEye</span></span></figcaption></figure><p>New Zealand’s <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30237-1/fulltext">public health response to the COVID-19 pandemic</a> may be the envy of the world, but as the new government looks ahead, potentially with a more progressive lens, it will have to face several challenges in the health sector.</p>
<p>New Zealand is recognised internationally for having a <a href="https://www.commonwealthfund.org/publications/other-publication/2020/jan/multinational-comparisons-health-systems-data-2019">good health system</a>. Unlike citizens of some other high-income countries, all New Zealanders have, in principle at least, access to free secondary health care.</p>
<p>But inequality is a major issue, leading to <a href="https://www.stats.govt.nz/news/new-zealand-life-expectancy-increasing">shortened average life expectancy</a> and more health problems for Māori, <a href="https://www.stats.govt.nz/news/new-zealand-life-expectancy-increasing">Pasifika communities</a> and New Zealanders <a href="https://pubmed.ncbi.nlm.nih.gov/24929569/">living with disabilities</a>. </p>
<p>People also cite cost as a <a href="https://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-2017-international-comparison-reflects-flaws-and">barrier to accessing health services</a> and there are <a href="https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/atlas-of-healthcare-variation/">stark regional differences</a> in service (in access, provision and outcome) and in support for those experiencing major illness, such as cancer, <a href="https://healthcentral.nz/overhaul-acc-to-cover-illness-not-just-injuries-argues-sir-geoffrey-palmer/">compared to those with major injury</a>. </p>
<h2>Improving health outcomes for all</h2>
<p>Among the first non-COVID-19 health challenges for the government will be to decide whether to implement any recommendations from the recent <a href="https://systemreview.health.govt.nz/">Health and Disability System review</a>, commissioned by the previous Labour-NZ First coalition government. </p>
<p>The first requirement for the review panel was to “recommend how the system could be designed to achieve better health and well-being outcomes for all” — and it highlighted addressing equity. The panel recommended adequate funding and an increased focus on public health as important steps towards achieving equity. </p>
<p>Achieving more equitable outcomes for Pasifika communities, people living in poverty or with disabilities and other marginalised groups is crucial. But the first priority should be to honour the Tiriti o Waitangi (<a href="https://nzhistory.govt.nz/politics/treaty-of-waitangi">Treaty of Waitangi</a>) by embedding genuine partnerships with Māori at all levels of our health system. </p>
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Read more:
<a href="https://theconversation.com/two-inquiries-find-unfair-treatment-and-healthcare-for-maori-this-is-how-we-fix-it-144939">Two inquiries find unfair treatment and healthcare for Māori. This is how we fix it</a>
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<p>Some health organisations have deliberately <a href="https://pharmac.govt.nz/news-and-resources/news/inaugural-chief-advisor-maori-appointed-to-pharmac/">appointed Māori health leaders</a> to executive levels to advance equity for Māori. But genuine partnership must ensure <a href="https://www.nzma.org.nz/journal-articles/unravelling-the-whariki-of-crown-maori-health-infrastructure">many Māori voices are at the table</a>, and <a href="https://www.tandfonline.com/doi/full/10.1080/1177083X.2018.1561477">heard</a> — from local health committees to boards and executive leadership teams throughout the health system.</p>
<p>Consultation can not be the end point of equity partnerships. They must move to financial and decision-making empowerment. Most of the review panel, as well as the Māori advisory group, recommended a proposed Māori Health Authority, which should:</p>
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<p>commission health services … for Māori using an indigenous-driven model within the proposed system to achieve equity.</p>
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<p>The government must look closely at this as well as the Waitangi Tribunal’s <a href="https://forms.justice.govt.nz/search/Documents/WT/wt_DOC_152801817/Hauora%20W.pdf">report</a> on the <a href="https://waitangitribunal.govt.nz/inquiries/kaupapa-inquiries/health-services-and-outcomes-inquiry/">Health Services and Outcomes Inquiry</a> to support Māori aspirations for tino rangatiratanga (self-governance) and mana motuhake (autonomy, independence). </p>
<p>The government also needs to explicitly address <a href="https://www.nzma.org.nz/journal-articles/racism-and-health-in-aotearoa-new-zealand-a-systematic-review-of-quantitative-studies">racism in the health system</a>, which underlies health inequities. </p>
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Read more:
<a href="https://theconversation.com/maori-and-pasifika-leaders-report-racism-in-government-health-advisory-groups-112779">Māori and Pasifika leaders report racism in government health advisory groups</a>
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<h2>Cost barriers and regional differences</h2>
<p>Another challenge will be to get the balance right between regional and central decision-making. </p>
<p>New Zealand has a small and geographically dispersed population, and currently, more than three-quarters of public health funds go to <a href="https://www.health.govt.nz/new-zealand-health-system/overview-health-system/funding">20 regional district health boards</a>. These regional authorities plan, buy and provide health services within their respective areas.</p>
<p>The Health and Disability System review proposed a new agency, Health NZ, which would be separate from the Ministry of Health and responsible for leading health service delivery, with fewer district health boards. If Health NZ is established, its mandate could include reducing regional differences in access to, and quality of, care.</p>
<p>The current health funding also creates barriers to accessing primary care services. For many people, the cost of seeing a GP or after-hours service is too high, and these barriers fall unfairly. </p>
<p>Past governments have taken steps to increase the eligible age for free youth primary care services. GP visits are currently free for children under 14 — an improvement on the earlier age limit of six. These are positive steps and could be expanded to include all youth and marginalised groups. </p>
<h2>Public versus private healthcare</h2>
<p>New Zealand’s health care is a dual system of public and private provision.</p>
<p>People who can’t <a href="https://pubmed.ncbi.nlm.nih.gov/19322811/">afford health insurance or private health care</a> sometimes face long <a href="https://www.nzherald.co.nz/nz/public-v-private-healthcare-does-the-conflict-cause-long-wait-times/C7ZAJ26WPGALBVC3QUFVC2EOYE/">waiting times for surgery and other hospital services</a>. The new government could improve access by learning from initiatives in other countries, including a recent <a href="https://www.bccourts.ca/jdb-txt/sc/20/13/2020BCSC1310.htm#SCJTITLEBookMark3957">high-profile judgement</a> in British Columbia, Canada, which argued health care should be guided by <a href="https://www.cbc.ca/news/canada/british-columbia/cambie-surgeries-case-trial-decision-bc-supreme-court-2020-1.5718589">medically necessary care</a>, not the ability to pay.</p>
<p>New Zealand also has a strong and unique system of universal <a href="https://www.acc.co.nz/">no-fault accident compensation</a>. It looks after injured New Zealanders, from injury to rehabilitation, including salary support. </p>
<p>But people affected by illness have fewer services and only very limited means-tested financial support options available to them. The inequities arising from this include the obvious differences in financial and rehabilitation support, but also fewer people of working age with an illness <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953613001342">returning to paid employment</a>.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-zealands-catch-up-patch-up-health-budget-misses-the-chance-for-a-national-overhaul-138509">New Zealand’s ‘catch up, patch up’ health budget misses the chance for a national overhaul</a>
</strong>
</em>
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<h2>Building on Labour Party history</h2>
<p>In 1935, in a landslide, Michael Joseph Savage led the Labour Party to its first electoral victory. His government had a clear mandate and went on to establish New Zealand’s universal health-care system in 1938. </p>
<p>Jacinda Ardern’s leadership has shown we can act decisively in the face of a pandemic with, so far, relatively equitable health outcomes (although a <a href="https://www.rnz.co.nz/international/pacific-news/425296/former-cook-islands-pm-dies-in-auckland-from-covid">Pasifika leader</a> and two <a href="https://www.teaomaori.news/man-dies-covid-19-part-auckland-cluster">Māori men died</a> in the August outbreak in Auckland). </p>
<p>The new Labour government could use its mandate to implement changes to health services with the explicit goal of realising health equity. Opportunities for this exist in genuine partnership with Māori at all levels of the health system and mandatory anti-racist systems and processes. </p>
<p>Further goals should include reducing regional variation, continuing to remove cost barriers and, finally, realising Justice Sir Owen Woodhouse’s <a href="https://www.acc.co.nz/about-us/who-we-are/our-history/#1967--the-woodhouse-report--foundations-of-acc">1967 vision</a> of a united no-fault system of support for all New Zealanders in need, regardless of whether they have experienced major illness or injury.</p><img src="https://counter.theconversation.com/content/148421/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah Derrett has received Health Research Council (HRC) of New Zealand funding for research investigating outcomes after injury. Sarah Derrett an executive committee member of Bowel Cancer New Zealand - a patient and family-led charity.</span></em></p><p class="fine-print"><em><span>Patricia Priest does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New Zealanders have, in principle, access to free healthcare. But inequality is a major issue, affecting Māori and Pasifika communities and New Zealanders living with disabilities or in poverty.Sarah Derrett, Professor, University of OtagoPatricia Priest, Assciate Professor in Epidemiology, University of OtagoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1444432020-08-25T15:56:12Z2020-08-25T15:56:12ZUnhealthy reforms: The dangers of Alberta’s plan to further privatize health-care delivery<figure><img src="https://images.theconversation.com/files/354138/original/file-20200821-16-rf2jrf.jpg?ixlib=rb-1.1.0&rect=41%2C8%2C2556%2C1881&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Alberta Minister of Health Tyler Shandro speaks during a press conference in Calgary on May 29, 2020. The Alberta government is proposing legislation to accelerate approvals of private clinics in order to get more surgeries done.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Jeff McIntosh</span></span></figcaption></figure><p>The Alberta government recently passed <a href="https://docs.assembly.ab.ca/LADDAR_files/docs/bills/bill/legislature_30/session_2/20200225_bill-030.pdf">legislation</a> to increase the role of corporations in the health-care system and facilitate the government’s goal of having <a href="https://www.theglobeandmail.com/canada/alberta/article-alberta-to-use-rural-hospital-private-clinics-for-minor-surgeries/">30 per cent of the province’s surgeries performed in private facilities</a>. </p>
<p>These changes risk undermining the public health-care system, increasing costs and decreasing quality. <a href="https://edmontonjournal.com/news/politics/proposed-200-million-private-health-facility-a-huge-concern-critics-say">Media reports</a> about a proposed private surgical facility suggest that the government may be putting profits over the public good in implementing the reforms.</p>
<h2>Corporatization of health delivery</h2>
<p>The legislative changes allow corporations to make financial arrangements with the government to provide health services, and to contract with physicians to deliver those services. </p>
<p>This is a departure from the current system in which only physicians (either directly or through their professional corporations) could bill the government for providing health services. Unlike physicians, who must place the interests of their patients above their own personal and financial interests, corporations owe financial obligations to their shareholders that may conflict with the interests of patients.</p>
<h2>Privatization of health delivery</h2>
<figure class="align-center ">
<img alt="Close-up of a male surgeon's face looking down, wearing a surgical mask and cap, glasses and a forehead-mounted light." src="https://images.theconversation.com/files/354136/original/file-20200821-18-1of5rrs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/354136/original/file-20200821-18-1of5rrs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/354136/original/file-20200821-18-1of5rrs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/354136/original/file-20200821-18-1of5rrs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/354136/original/file-20200821-18-1of5rrs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/354136/original/file-20200821-18-1of5rrs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/354136/original/file-20200821-18-1of5rrs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">With the expansion of private delivery, a larger variety of surgical procedures will be performed in private clinics.</span>
<span class="attribution"><span class="source">(Unsplash/National Cancer Institute)</span></span>
</figcaption>
</figure>
<p>The new legislation also facilitates the private delivery of publicly funded surgeries. Although some services are already <a href="https://www.albertahealthservices.ca/about/Page3172.aspx">delivered privately</a> (most commonly cataract surgery), many more surgeries and a <a href="https://www.cbc.ca/news/canada/edmonton/mastectomies-hernias-possibilities-for-private-surgical-delivery-1.5448131">larger variety of procedures</a> will now be performed in private, for-profit, facilities. </p>
<p>For-profit delivery <a href="https://www.policyalternatives.ca/sites/default/files/uploads/publications/BC%20Office/2016/04/CCPA-BC-Reducing-Surgical-Wait-Times.pdf">tends to cost more</a> than non-profit delivery, given the need to deliver returns to investors. In a <a href="https://s3-us-west-2.amazonaws.com/parkland-research-pdfs/deliverymatters2.pdf">previous experiment with privatization</a>, surgeries cost more in the private facility than in the public system, and Albertan taxpayers bailed out the facility when it ran into financial difficulties. Evidence also suggests that <a href="https://www.cmaj.ca/content/166/11/1399?ijkey=7977d3b90df49620fcd42cd7a14f9c8895cd1139&keytype2=tf_ipsecsha">for-profit facilities tend to deliver lower quality care</a> than non-profit facilities.</p>
<p>The government’s stated rationale for increased private delivery is to reduce wait times. This claim <a href="https://www.longwoods.com/content/26228//commentary-the-consequences-of-private-involvement-in-healthcare-the-australian-experience">runs contrary to evidence</a> that indicates that reallocating finite health professional hours to the private system increases wait times in the public system. </p>
<p>Because private facilities generally <a href="https://doi.org/10.1002/hpm.2502">prefer healthier patients with less complex medical needs</a>, those with more complex needs will be left waiting longer for care in public hospitals. Recruiting additional staff to address these issues would be difficult, given the government’s <a href="https://www.cbc.ca/news/canada/calgary/alberta-kenney-doctors-government-1.5653948">strained relationship</a> with physicians. </p>
<h2>Centralization of government control</h2>
<p>Perhaps in a bid to minimize opposition to its controversial reforms, the government is also <a href="https://healthydebate.ca/opinions/alberta-key-health-institutions">asserting control over key health institutions</a>. For example, the new legislation shrinks the responsibilities of Alberta Health Services (AHS), the entity responsible for contracting with private providers, and allows the government to impose an accountability framework on AHS.</p>
<figure class="align-center ">
<img alt="View of Alberta legislature from above, in winter." src="https://images.theconversation.com/files/354139/original/file-20200821-20-ejt11a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/354139/original/file-20200821-20-ejt11a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=418&fit=crop&dpr=1 600w, https://images.theconversation.com/files/354139/original/file-20200821-20-ejt11a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=418&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/354139/original/file-20200821-20-ejt11a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=418&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/354139/original/file-20200821-20-ejt11a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=525&fit=crop&dpr=1 754w, https://images.theconversation.com/files/354139/original/file-20200821-20-ejt11a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=525&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/354139/original/file-20200821-20-ejt11a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=525&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">View of the Alberta Legislature in Edmonton on March 28, 2014. A recent proposal by the Alberta government could increase its control over institutions that regulate health professionals.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jason Franson</span></span>
</figcaption>
</figure>
<p>The government recently <a href="https://www.albertadoctors.org/services/media-publications/presidents-letter/pl-archive/possible-changes-hpa-self-regulation-concerns">circulated a proposal</a> that could increase its control over the key functions of institutions that regulate health professionals. Because one of these institutions, the College of Physicians and Surgeons, is responsible for accrediting and setting standards for private surgical facilities, the proposal could be a way of influencing that process. </p>
<p>The government has also <a href="https://www.longwoods.com/content/26298//proposed-legislation-erodes-independence-and-expertise-of-alberta-s-healthcare-institutions">increased the number of public members on self-regulatory bodies</a>. Given the government’s influence on the appointment process, this may also be a means of increasing its control over these bodies.</p>
<h2>Implementing private delivery</h2>
<p>Details have emerged about <a href="https://www.cbc.ca/news/canada/edmonton/private-orthopedic-surgical-alberta-health-1.5678883">discussions between Ministry of Health officials and a group of surgeons, developers and lobbyists</a> regarding a proposed $200-million facility that would perform most orthopedic surgeries in the Edmonton region. These discussions illustrate how private delivery can prioritize profits over the public interest. </p>
<p>This facility is likely to benefit from public subsidies. For example, if procedures performed in private facilities result in serious complications, or if patients require readmission to hospital, public hospitals will likely be responsible for treating these patients. </p>
<p>In addition, acquiring land and constructing the facility will require public investment, whether by way of direct funds, tax credits or by allowing the facility to recoup its costs through service contracts negotiated with the government. Furthermore, the investors are reportedly insisting on contractual terms that will make their contract with the government <a href="https://www.cbc.ca/news/canada/edmonton/experts-raise-alarm-about-proposed-largest-private-surgical-facility-in-alberta-history-1.5679074">expensive to cancel and binding on future governments</a>, placing financial risks on taxpayers. </p>
<p>There are also transparency problems with the project. Lobbyists had access to high-level government officials, raising concerns that lobbying efforts rather than public interest will influence who receives private contracts, the terms of those contracts and how these facilities will be regulated. </p>
<p>The opposition party has <a href="https://www.cbc.ca/news/canada/edmonton/alberta-auditor-general-review-requested-in-private-orthopedic-surgical-facility-1.5683305">asked the auditor general to investigate</a>, alleging political interference in the procurement process. AHS was <a href="https://www.cbc.ca/news/canada/edmonton/experts-raise-alarm-about-proposed-largest-private-surgical-facility-in-alberta-history-1.5679074">excluded from the discussions</a> and will reportedly be pressured to accept the initiative. </p>
<p>Recent reforms embracing the corporatization and privatization of health services undermine the public health-care system and risk prioritizing profits over patients and taxpayers. However, challenges to public health care are not limited to Alberta. </p>
<p>For example, <a href="https://www.huffingtonpost.ca/colleen-m-flood/public-vs-private-healthcare-canada_b_7136996.html">ongoing litigation in British Columbia</a> threatens laws limiting private finance, and Saskatchewan has been engaged in a lengthy <a href="https://www.cbc.ca/news/canada/saskatchewan/sask-mri-federal-money-1.5483849">dispute with the federal government over private MRIs</a>. </p>
<p>These privatization efforts threaten the basic tenet of the Canadian health-care system: access based on need rather than ability to pay.</p><img src="https://counter.theconversation.com/content/144443/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Recent Alberta legislation increasing privatization in the health sector risks undermining the public health-care system, and will likely put profits over the public interest.Lorian Hardcastle, Associate Professor, Faculty of Law and Cumming School of Medicine; Member, AMR One Health Consortium, University of CalgaryUbaka Ogbogu, Associate Professor, Faculty of Law and Faculty of Pharmacy and Pharmaceutical Sciences, University of AlbertaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1433562020-07-27T16:03:43Z2020-07-27T16:03:43ZCOVID-19 exposes weaknesses in Kenya’s healthcare system. And what can be done<figure><img src="https://images.theconversation.com/files/349325/original/file-20200724-33-1qvn0p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse participates in the drill to test their system capabilities for the COVID-19 coronavirus mass patients influx at the Aga Khan University Hospital in Nairobi.</span> </figcaption></figure><p><em>There are <a href="https://www.nation.co.ke/kenya/news/top-hospitals-running-out-of-icu-beds-covid-19--1444712">reports</a> that Kenya’s hospital beds are filling up because of a surge in COVID-19 patients. This highlights concerns since the start of the pandemic, that the health systems of many African countries would quickly become overwhelmed. Moina Spooner from The Conversation Africa asked Professors Abdu Mohiddin and Marleen Temmerman to explain what must be done.</em></p>
<p><strong>What are the major deficiencies in Kenya’s healthcare system?</strong></p>
<p>Kenya’s healthcare system is made up of several systems: public, private and faith-based or NGO. <a href="https://www.the-star.co.ke/news/2020-07-07-access-to-health-care-services-has-improved-report/">About</a> 48% are public and operate under the Ministry of Health, 41% are in the private sector, 8% are faith-based health services, and 3% are run by NGOs.</p>
<p>Healthcare in public hospitals is free for some services, such as maternity care, and for those with national health insurance, in-patient treatment is free. Healthcare provided by private hospitals, faith-based institutions or NGOs usually comes at a cost and charges will vary.</p>
<p><a href="http://www.healthpolicyplus.com/ns/pubs/11323-11587_KenyaHealthFinancingSystemAssessment.pdf">About</a> 20% of Kenyans have some form of health insurance coverage, including national health insurance, but this varies by region. <a href="http://www.healthpolicyplus.com/ns/pubs/11323-11587_KenyaHealthFinancingSystemAssessment.pdf">For instance</a>, 41% of residents in Nairobi have cover, while under 3% will have cover in marginalised rural areas such as Wajir and West Pokot.</p>
<p>In the public sector, the 47 <a href="https://www.nation.co.ke/kenya/news/covid-19-what-uhuru-told-governors-at-coronavirus-summit-1906894">county governments</a> deal with service provision at the local level, while the national level is concerned with policy and the referral hospitals. </p>
<p>Taking all the healthcare systems in Kenya together, the fundamental shortcoming is the mismatch between needs and the available care, in particular specialist care and the workforce – from doctors to technicians – needed to run it. </p>
<p>For instance, a <a href="https://pubmed.ncbi.nlm.nih.gov/29191247/">nationwide study</a> found major shortages in chest specialists, hospital physicians and emergency care nurses. An assessment of health facilities in 2018 also <a href="https://www.health.go.ke/wp-content/uploads/2020/01/KHFA-2018-19-Popular-version-report-Final-.pdf">reported that</a> just 12% had the standard items needed to prevent infections, such as gloves, infectious waste storage and disinfectant. Of the hospitals that offer emergency breathing intervention services, 78% offered administration of oxygen and 23% had invasive mechanical ventilation.</p>
<p>The mismatch between available care and needs manifests in two main ways: geographically and economically.</p>
<p>Geographically, there’s a huge divide between what’s available in rural areas and urban areas. Most Kenyans, <a href="https://kenyanwallstreet.com/census-2019-datashows-kenya-has-a-youthful-rural-population/">about 70%</a> of the population, live in rural areas. They mostly rely on community health volunteers and health facilities that are staffed by nurses who provide primary health care services like immunisation. Sub-county hospitals provide more services and a few medical doctors are available.</p>
<p>Economically, those who are poorer or uninsured are less able to access what is available. If they can access healthcare, <a href="https://gh.bmj.com/content/4/6/e001809">they risk</a> huge bills which can push them into poverty. </p>
<p>Another challenge is corruption. This manifests dangerously in various ways throughout the system. For instance, a major concern is the cartels within the Ministry of Health which <a href="https://www.nation.co.ke/kenya/news/politics/kagwe-transfers-30-officers-in-battle-against-cartels-288426">are accused</a> of colluding to steal public funds. Such theft weakens health institutions and diverts valuable time and attention to its mitigation. </p>
<p>In addition, some officials from the main supplier of medical goods – Kenya Medical Supplies Agency – <a href="https://www.standardmedia.co.ke/article/2001375820/anti-graft-agency-probes-illegal-dealings-at-kemsa">are under</a> investigation for awarding protective equipment tenders irregularly.</p>
<p>Ultimately, the major challenge is that this is a healthcare system where most people <a href="https://www.ieakenya.or.ke/number_of_the_week/kenyaa-s-comparison-of-out-of-pocket-expenditure-on-health-with-its-peers">are able</a> to access basic care but they face the barrier of potentially <a href="https://gh.bmj.com/content/4/6/e001809">catastrophic</a> fees.</p>
<p><strong>What has contributed to this?</strong></p>
<p>Over many years health has not had the political priority it needs with attendant impacts on investment, strategic thinking and planning. </p>
<p>Two examples show this:</p>
<p>First, Kenya’s government health expenditure isn’t enough. Over the last two decades, it <a href="https://www.who.int/health_financing/documents/public-financing-africa/en/">has averaged</a> about half the <a href="https://apps.who.int/iris/bitstream/handle/10665/249527/WHO-HIS-HGF-Tech.Report-16.2-eng.pdf;jsessionid=147923A8321E6650890571BD9D2128C8?sequence=1">Abuja declaration’s</a> target of at least 15% of national budgets. This was set in 2001 by African Union heads of state. </p>
<p>Secondly, the local and national health systems aren’t resilient to shocks. For instance, the <a href="https://theconversation.com/nurses-strike-shows-poor-management-of-health-care-in-kenya-86473">2017 national strike</a> by health care workers caused major nationwide service disruptions and the closure of several facilities. </p>
<p><strong>How will the COVID-19 pandemic heighten these challenges and what is the government doing to address them?</strong></p>
<p>Overall, Kenya faces huge coordination and planning challenges between all health systems, at the local and national level. For instance, while the national government is showing leadership with COVID-19 taskforces on mitigation measures and communication, it’s not being uniformly implemented at the county level. </p>
<p>There’s also a lack of information on what is or isn’t working. This includes <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31601-9/fulltext">data on</a> whether national directives – such as curfews and lockdowns – have been effective in breaking transmission.</p>
<p>In addition to this, there’s a huge lack of resources. For this pandemic, intensive care beds and ventilators are critical. But <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236308">recent studies</a> show that while Kenya has 537 intensive care beds, it has only 256 ventilators. </p>
<p>Many counties simply don’t have specialist equipment. <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236308">Only 22</a> out of the 47 counties have at least one intensive care unit. Hundreds more units and ventilators are needed as well as the staff to run them. </p>
<p>In addition there is the stress to the system when staff get sick or have to go into quarantine. The staffing challenges are already an issue so this is a serious concern. </p>
<p>The government is taking certain steps to address these challenges. </p>
<p>It <a href="https://www.standardmedia.co.ke/health/article/2001379598/covid-19-pushes-ministry-budget-beyond-sh83b">recently increased</a> health spending from Ksh73 billion (about US$678 million) to Ksh83 billion (about US$771 million) this year and <a href="https://www.kbc.co.ke/govt-launches-primary-health-care-strategic-framework/">reiterated</a> its commitment to universal health coverage – though it’s not clear how far we are off this. One firm positive step is that <a href="https://www.capitalfm.co.ke/news/2020/07/govt-says-public-hospitals-not-charging-for-covid-treatment/">treatment for</a> COVID-19 in government hospitals is currently now free.</p>
<p>Funding all of this will, it appears, come from international donors, government borrowing and the reopening of the economy to improve tax revenues and sustainability. </p>
<p>Healthcare workers have been concerned about the availability and quality of personal protective equipment such as protective clothing, helmets and goggles. Threats of strike action <a href="https://www.capitalfm.co.ke/news/2020/05/health-ministry-says-talks-underway-to-avert-looming-strike-by-health-workers/">have been issued</a> and the government responded with talks to avert them. But there are concerns over substandard items and fakes due to corruption. </p>
<p><strong>What else needs to be done?</strong></p>
<p>Given the constraints the government faces in resources, preventing the spread of the virus and effective use of existing resources are critical. This includes firm commitments, and clear actions, by the country’s leaders that they’re taking preventative measures such as wearing masks and social distancing.</p>
<p>Leaders must also ensure that the regulations are enforced and there must be clear campaigns to deal with myths. </p>
<p>There must be better coordination between the government, private and faith or NGO institutions. This is particularly vital when it comes to specialist care. Coordination is happening but depends a lot on counties, which vary in their capacity. </p>
<p>Stakeholders, such as private facilities, are usually willing to work with the government <a href="https://www.standardmedia.co.ke/article/2001369339/private-hospitals-are-ailing-due-to-covid-19">provided</a> the issues of delayed payments can be remedied.</p>
<p>In addition, there must be more research on how the pandemic is spreading in Kenya and any new or appropriate technologies needed to mitigate and treat it. More data is also needed on COVID-19’s impact on health systems and society. </p>
<p>Some data are announced daily but detailed data are needed – for instance specific measures on how the virus is spread or information on how well the healthcare system is doing at all levels, such as length of stay in intensive care units, effectiveness of contact tracing teams or numbers of deaths in vulnerable communities. </p>
<p>Finally there are many routine healthcare system activities that are not happening or have been reduced. These include antenatal care, deliveries and immunisations. Mitigation actions and planning are urgently needed.</p><img src="https://counter.theconversation.com/content/143356/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Most Kenyans are able to access basic care but face the barrier of potentially catastrophic fees.Abdu Mohiddin, Assistant Professor, Aga Khan University Marleen Temmerman, Director of the Centre of Excellence in Women and Child Health and Chair of the Department of Obstetrics and Gynaecology (OB/GYN), Aga Khan University Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/997992018-07-30T13:54:16Z2018-07-30T13:54:16ZExplainer: how competitive is South Africa’s private health care sector<figure><img src="https://images.theconversation.com/files/227400/original/file-20180712-27045-moi0if.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>After a four and a half year probe initiated by South Africa’s Competition Commission, a panel of independent experts <a href="http://www.compcom.co.za/provisional-%20findings-and-recommendations-report/">released</a> their preliminary report into the country’s private health care market. The Conversation Africa spoke to Sharon Fonn, who was on the panel of experts, about the report.</em></p>
<p><strong>Why was a market inquiry set up?</strong></p>
<p>The inquiry was set up because private health care and medical scheme cover is expensive in South Africa. Costs continue to rise and fewer people can afford it. People who have health insurance find that the scheme covers less care and they often have to pay out of pocket.</p>
<p>Also, the private health care sector consumes a large amount of the health care spend and resources despite the fact that it only serves a small portion of the population. The private health care market serves about 18% of the population who buy health care insurance sold by medical schemes. But the private market consumes about half of the total health spend every year.</p>
<p><strong>What did you find about competition – or lack of – in the sector?</strong></p>
<p>The first thing to realise is that this is a complicated market with lots of different players in it so there isn’t a straightforward easy answer. It’s complex.</p>
<p><strong>The report talks about a funder market. What is this and what did you find?</strong></p>
<p>By funders we mean the companies that purchase health care. This includes medical schemes, the administrators that schemes use and the managed care organisations that the schemes contract with. We found that competition doesn’t operate as it should on the funder side of the market.</p>
<p>Basically what schemes do is pool the money that members of schemes give in premiums each month. The point of health insurance is to enable money to be pooled so that the healthy can cross-subsidise the sick. Over time it evens out.</p>
<p>Health insurance is there to protect people from catastrophic expenditure. Members should want their scheme to be careful and wise with their money.</p>
<p><strong>Is this not happening and if not why not?</strong></p>
<p>We think this isn’t happening for a number of reasons. It’s not to do with schemes being bad. It’s about the way the market operates.</p>
<p>One of the reasons it’s hard to know if schemes are being wise is that consumers don’t have the information they need. There are about 270 different health care plans on offer from all the various medical aid schemes – each offers different cover and costs a different amount. It’s very difficult to compare them and work out which option offers the best bang for a person’s buck.</p>
<p>We have recommended that all schemes have to offer a basic package that offers the same care. Consumers could then compare like with like. </p>
<p>On top of this there are also regulatory problems (rules about how schemes work) where we recommend changes so that it’s easier for schemes to offer a single comparable package. </p>
<p><strong>So one package is one solution. But how does a person know if the quality is good or bad?</strong></p>
<p>In the private market there are no measures of quality that are shared with
the public. Consumers don’t know if a hospital is good or bad. There is also no way to judge if care being provided by doctors and specialists is effective as there are no measures on whether or not people are better afterwards. </p>
<p>This can lead to more and more interventions – and a waste of money. </p>
<p>If data are pooled and lots of doctors and patients report about health outcomes, we can begin to know if having an extra test or some kind of intervention works. We make a recommendation about reporting on quality and outcomes. </p>
<p><strong>You looked at hospitals – what did you find?</strong></p>
<p>We found that is a very high level of concentration in the hospital sector. Three hospital groups dominate: Netcare, Mediclinic and Life. They have more than 80% of the hospital beds available and get 90% of all the admissions. This distorts and restricts competition. </p>
<p>We have made some recommendations around this. But one thing we think is essential is a supply side regulator that would, among other things, assist provinces in issuing licenses for hospitals. Some countries, like Germany, are very strict about the number of beds available in the hospital sector.</p>
<p><strong>The report also talks about doctors, what did you find?</strong></p>
<p>There are problems when it comes to the way doctors and specialists work. They work as individuals – not as a team. Team-based care is an internationally accepted standard because it provides better care and can be more cost effective. But our system doesn’t allow this easily. </p>
<p>Also doctors and specialists use a fee-for-service billing model. This means they bill patients for each service they perform during a consultation. Obviously people inclined to maximise their income they will do more so they earn more. There is no good mechanism to manage this.</p>
<p>This is a universal problem. Different countries have different ways of managing it. In Sweden, for example, almost all specialists are salaried and paid by the state. So they don’t have an incentive to do more to earn more. </p>
<p><strong>There is a chapter supply induced demand. What’s that about?</strong></p>
<p>Basically it means that when some additional care is offered (increased access), additional use of the service that would not have otherwise have happened takes place. </p>
<p>This has two consequences: wasteful expenditure and patients being over serviced. </p>
<p><strong>How does South Africa compare to other countries?</strong></p>
<p>When it comes to the private health care sector South Africa faces a problem of over-servicing and over supplying. Three examples illustrate this. </p>
<p>Firstly, hospital admission rates are extremely high. South Africa’s rate was higher than all but two of 17 other OECD countries we used as comparisons.</p>
<p>We also looked at seven different surgical procedures. In four, South Africa had the highest usage rates.</p>
<p>Lastly we looked at the number of people that get admitted to intensive care units. We found that South Africa had higher admission rates than eight other countries with comparable published data.</p>
<p><strong>What will it take to break the current patterns?</strong></p>
<p>We recommend that the regulatory regime needs to be improved. Regulators aren’t as sensitive to competition issues as they could be. South Africa has laws in place but they aren’t being fully used. Stewardship from the Department of Health has also been weak.</p>
<p>But we were also very aware that there is no quick fix. The market is incredibly complex. This means that several interrelated interventions are needed. Market failures will persist if the recommendations aren’t introduced as a package.</p>
<p>We also kept in mind that the country is trying to move towards a system of Universal Health Coverage and we have been mindful not to undermine that vision.</p>
<p><strong>What, in summary are your main recommendations?</strong></p>
<ul>
<li><p>The way in which schemes operate needs to change. This should include the way options are structured so that people can compare apples with apples. We hope that will improve accountability in the funder market. </p></li>
<li><p>More transparency: a system needs to be put in place that allows people to see what value they’re getting for what they’re paying for.</p></li>
<li><p>Greater competition, especially in the hospital sector is needed.</p></li>
</ul><img src="https://counter.theconversation.com/content/99799/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sharon Fonn receives funding from numerous agencies including AESA, Wellcome Trust, DfID, Carnegie Corporation of New York, and SIDA. </span></em></p>A market inquiry has looked into private health care costs in South Africa.Sharon Fonn, Professsor of Public Health; Co-Director Consortium for Advanced Research Training in Africa; Panel Member, Private Healthcare Market Inquiry, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/990282018-06-28T14:04:52Z2018-06-28T14:04:52ZSouth Africa’s universal health care plan falls short of fixing an ailing system<figure><img src="https://images.theconversation.com/files/225142/original/file-20180627-112604-12nm7oq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A patient collects her medication at a clinic in Khayelitsha, South Africa.</span> <span class="attribution"><span class="source">MSF/Sydelle WIllow Smith</span></span></figcaption></figure><p>South Africa’s Health Minister Aaron Motsoaledi has finally gazetted the bill detailing an ambitious plan to roll out universal health care in the country through a <a href="https://www.gov.za/sites/default/files/41725_gon635s.pdf">National Health Insurance</a>. </p>
<p>The bill responds to a global campaign spearheaded by the <a href="http://www.who.int/universal_health_coverage/en/">World Health Organisation</a> and linked to the <a href="http://indicators.report/targets/3-8/">UN’s sustainable development goals</a> to make sure that no-one is left behind in accessing quality health care. </p>
<p>There’s no dispute that South Africa’s health care system needs major reforms. There are considerable inequities in health care between <a href="https://theconversation.com/a-human-step-to-equal-health-care-in-south-africas-rural-hospitals-41648">urban and rural areas</a>; between public and private <a href="https://scholarworks.wmich.edu/cgi/viewcontent.cgi?article=3752&context=honors_theses">health sectors</a> and between primary health care and hospital care. And the country has a complex disease burden with heavy caseloads of <a href="https://theconversation.com/scientists-are-combining-forces-to-tackle-the-deadly-duo-of-tb-and-hiv-62378">HIV, TB</a> and <a href="https://theconversation.com/south-africas-sugar-tax-a-bold-move-and-the-right-thing-to-do-72010">non-communicable diseases</a>. </p>
<p>South Africa has poor health outcomes compared to other middle-income countries such as Brazil with similar health spending as a percentage of GDP. It spends more than R300 billion – or around 8.5% of its gross domestic product – on health care. But half is spent in the private sector catering for people who are well off while the remaining 84% of the population, which carries a far greater burden of disease, depends on the under-resourced public sector. </p>
<p>The health system performs poorly due to a combination of factors including the poor management of public sector hospitals, health professional shortages (particularly in rural areas), low productivity levels among staff, escalating private health care costs and poor quality of care. </p>
<p>But in its current form the proposed legislation won’t be a silver bullet. There are still too many inconsistencies and unanswered questions for it to be the final roadmap to universal health care in the country. </p>
<p>For example, the bill focuses on curative services, missing an opportunity to take a public health approach that focuses on disease prevention, health promotion and health protection. In addition, it doesn’t address the relationship between the public and private health sectors which is seen as a major impediment to fundamental change. </p>
<h2>How it will work</h2>
<p>The bill is informed by a vision of ensuring equitable access to quality health services, regardless of a person’s ability to pay or whether they live in an urban or rural area. The proposed insurance fund envisages the consolidation of public and private revenue into one funding pool. </p>
<p>The idea is to enable a more equitable system through, for example, cross-subsidisation and ensuring that essential services are made available. </p>
<p>All people will have to register as users of the fund at an accredited health care establishment or facility (whether public or private). And the fund will decide on the health benefits that the facilities will have to provide. This will depend on what resources the facility has. People will be able to pay for complementary health service benefits not covered by the fund. </p>
<p>To be paid, health care providers, such as general practitioners and hospitals, will have to register with the fund. They will have to claim for each patient that they treat and will have to keep a record of diagnosis, treatment and length of stay.</p>
<h2>Governance</h2>
<p>The structure that’s been proposed for the fund is raising concerns on two fronts: it appears unnecessarily cumbersome and there’s a lack of clarity on lines of command.</p>
<p>The bill makes provision for the fund to establish an independent board that will report to South Africa’s Parliament. But it makes no mention of how the board will engage with the health minister (political custodian) and public servants in the health department. Nor does it explain how the performance of the fund will be evaluated. </p>
<p>The bill also introduces two additional management layers: district health management offices and contracting units for primary health care. These units will provide primary health care services in specific areas. It includes a district hospital, clinics and community health centres as well as ward-based outreach teams and private primary care service providers. They will be contracted by the fund. </p>
<p>National, provincial, and municipal health departments will still exist. </p>
<p>But the bill fails to explain the relationship between the district health management offices and the contracting units and how they will engage with the national, provincial and municipal health departments. </p>
<p>Given that there are ten health departments operating in South Africa – a national department and one in each of the country’s nine provinces – these additional offices and units could result in a more cumbersome bureaucracy. This could lead to more inefficiency and greater opportunity for corruption. </p>
<p>The new structure will also change the responsibilities of provincial health departments. Some of the proposals don’t make sense such as the idea that municipalities should take control of managing communicable diseases. Ideally this should be a national function, given the serious threat that is posed by some infectious diseases. </p>
<h2>Many questions</h2>
<p>Other parts of the bill are also unclear. These range from financing to how complaints will be managed.</p>
<p><strong>Health financing and management:</strong> The bill doesn’t explain what the tax implications of the national health insurance will be for citizens. It also doesn’t set out the mechanisms that will be put in place to strengthen financial planning and monitoring systems, particularly in the public health sector. These are very important given current <a href="https://www.news24.com/Archives/City-Press/R12bn-unaccounted-for-in-Gauteng-health-department-20150429">chronic overspending</a>, inadequate financial management and corruption and lack of accountability in many <a href="https://www.thesouthafrican.com/public-health-fail-report-reveals-that-sas-health-facilities-are-in-crisis/">provincial health departments</a>.</p>
<p><strong>Service provision:</strong> The bill says everyone is entitled to a comprehensive package of services at all levels of health care. But it doesn’t spell out what these packages will include. Given budgetary constraints, it’s obvious that there will inevitably have to be trade-offs and difficult choices. </p>
<p><strong>The health workforce:</strong> South Africa doesn’t have a comprehensive health workforce strategy with detailed norms and standards. This remains the Achilles heel of health sector reform in the country. The lack of detail remains a serious omission in the bill. </p>
<p><strong>Complaints mechanisms:</strong> The bill introduces a new separate complaints directorate – the investigating unit. But it’s unclear whether this will be the first level of complaints or whether it’s a duplication of the complaints directorate in the existing Office of Health Standards Compliance. There also isn’t clarity about where the Health Ombud fits in. </p>
<p>Ensuring that South Africa has a quality affordable health care system is critical. And the bill presents an important opportunity to think systematically about what needs to be done to fix the current health system. But there is still a long way to go.</p><img src="https://counter.theconversation.com/content/99028/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laetitia Rispel receives funding from the National Research Foundation. </span></em></p>The bill to provide universal health care in South Africa is not the silver bullet for the challenges in the health sector.Laetitia Rispel, Professor of Public Health and DST/NRF Research Chair., University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/973722018-05-30T20:01:26Z2018-05-30T20:01:26ZSpecialists are free to set their fees, but there are ways to ensure patients don’t get ripped off<figure><img src="https://images.theconversation.com/files/220904/original/file-20180530-120514-ekemsu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Specialists making their fees publicly available is one way to rein in rogue practices.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Monday’s <a href="http://www.abc.net.au/4corners/mind-the-gap/9809314">Four Corners program</a> drew attention to the issue of high fees charged by some specialist doctors, causing large out-of-pocket expenses for Australian patients. The program included examples of patients paying out-of-pocket fees totalling in the tens of thousands for hip replacements, prostate and breast cancer surgery. </p>
<p>While the ABC made the problem of specialist overcharging seem huge, the program did rely mostly on anecdotal evidence for the claims it made.</p>
<p>So, how big is this problem really, and what can we do about it?</p>
<h2>How specialist fees work</h2>
<p>Firstly we have to understand how specialist fees work and why this can lead to large out-of-pocket costs. </p>
<p>The Australian government funds consultations with, and procedures carried out by specialist doctors – outside public hospitals – through the <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home">Medicare Benefits Schedule</a>. Medicare sets a schedule fee for such consultations and procedures. The fee is indexed to rise each year, apart from <a href="http://www.abc.net.au/news/2016-05-30/medicare-rebate-freeze-what-you-need-to-know/7458796">the past five years</a> where these fees have been frozen. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Medicare subsidises specialist doctor’s fees up to a point, but the gap the patient pays depends on what fee the doctor sets.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The Medicare rebate is a percentage of the schedule fee; for instance 75% for specialist items, 100% for certain GP items. But the schedule fee doesn’t restrict doctors from charging a higher fee (the gap), which may or may not be covered by health insurance for in-hospital items. </p>
<p>Health insurance in Australia can’t cover doctors’ fees for out-of-hospital consultations. Doctors are free to charge whatever fee they like; there is no restriction on their pricing.</p>
<p>Medicare <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/annual-medicare-statistics">publishes some data</a> about bulk-billing rates and out-of-pocket costs. From this, we know only around 35% of specialists observe the schedule fee with an average out-of-pocket of A$75 in 2016/17. Worryingly, this average fee grew by nearly 6% from the previous financial year. But, these figures are nowhere near the extreme cases highlighted on Four Corners.</p>
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Read more:
<a href="https://theconversation.com/why-do-specialists-get-paid-so-much-and-does-something-need-to-be-done-about-it-74066">Why do specialists get paid so much and does something need to be done about it?</a>
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<p>Relatively little is published about the highest fees. One <a href="https://www.mja.com.au/system/files/issues/206_04/10.5694mja16.00653.pdf">recent study</a> with access to data on the distribution of fees for specialist consultations showed that at the 90th percentile, out-of-pocket costs were between A$85-$212, across all specialties. This is just for initial consultations – total costs for operations (which may include anaesthetist’s fees and other costs) are substantially higher. </p>
<p>So while we know the cases highlighted on Four Corners are not representative of the average specialist, or even of the some of the higher-charging doctors, out-of-pocket costs for private specialists are still high and rising at twice the rate of inflation. </p>
<p>So, what can be done to keep a lid on these price rises?</p>
<h2>Transparency and incentives</h2>
<p>The first potential solution is price transparency. Hopefully the government is seriously contemplating a system that would mandate all doctors publish their fees on a publicly accessible website. </p>
<p>On Four Corners, the Chief Medical Officer, Brendan Murphy, indicated this step is seriously being considered by the <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2018-hunt002.htm">advisory committee on out-of-pocket costs</a> that he is leading. It would be reassuring to see statements from ministers and the Australian Medical Association (AMA) to give this idea some real traction.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/many-australians-pay-too-much-for-health-care-heres-what-the-government-needs-to-do-61859">Many Australians pay too much for health care – here's what the government needs to do</a>
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<p>And while transparency would be a good step, it still ignores the fact Australia is an outlier in allowing doctors such unfettered freedom to set prices as they see fit. </p>
<p>Other comparable systems where doctors receive fee-for-service payments such as France and Canada, don’t allow their doctors freedom to charge as they like. In 2010, Australia was <a href="https://www.oecd-ilibrary.org/docserver/5kmfxfq9qbnr-en.pdf?expires=1527645664&id=id&accname=guest&checksum=DBD13F453B4AB88AAC0D90081B5A1D93">identified as the only country</a> in the OECD that allowed doctors complete price freedom. </p>
<p>While a complete overhaul of our health system is unlikely in the short-term, we could still make progress in the existing system. A radical solution could use some of the power of the Medicare Benefits Schedule to give specialists financial incentives to keep their prices low. </p>
<p>This might seem like a tricky concept to implement, but it’s actually been done before, and successfully, with the so-called “bulk-billing incentives” for GP consultations. Introduced in the mid 2000s, these incentives pay an extra rebate of A$6-$9 to GPs for each bulk-billed consultation where patients pay no out-of-pocket fee. </p>
<p>These incentives seem to be at least partly responsible for a large increase in the bulk-billing rate <a href="https://theconversation.com/factcheck-were-just-67-of-gp-visits-bulk-billed-when-tony-abbott-was-health-minister-17652">over the past 15 years</a>. </p>
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Read more:
<a href="https://theconversation.com/factcheck-are-bulk-billing-rates-falling-or-at-record-levels-72278">FactCheck: are bulk-billing rates falling, or at record levels?</a>
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<p>Similar “schedule fee incentives” could be introduced for specialists, which pay an extra Medicare rebate if the total fee is within some acceptable range. For example, specialists could be paid an extra incentive of A$10 if their total fee is no more than 10% higher than the schedule fee.</p>
<p>The amounts and conditions could be changed over time in response to how the market reacts to these changes. As shown by the impact of the bulk-billing incentives, the incentive amount might not have to be high to have a substantial impact in keeping prices low.</p>
<p>While not a silver bullet, radical reforms should be considered to mitigate the rise in specialist out-of-pocket fees before a full-blown crisis emerges.</p><img src="https://counter.theconversation.com/content/97372/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Sivey receives funding from the Australian Research Council.</span></em></p>Australia is the only country in the OECD that allows specialists complete freedom to set their own fees. This puts patients at risk – but the government can help protect them.Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/493012015-10-26T04:34:19Z2015-10-26T04:34:19ZUniversal health coverage means more than access and affordability – quality matters too<figure><img src="https://images.theconversation.com/files/99486/original/image-20151023-27619-7wsg42.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Although health care has become more accessible and affordable, quality at the facilities is still a problem.</span> <span class="attribution"><span class="source">Reuters/Siphiwe Sibeko</span></span></figcaption></figure><p>Moderate strides have been taken to make South Africa’s public health services accessible and affordable. But problems of quality persist. Evidence of this is that people still prefer private healthcare providers. </p>
<p>Post-1994, the emphasis has been on making healthcare services more available, and payment systems have been redesigned to increase affordability. This has seen an increasing share of government spending channelled into public health care. </p>
<p>But this fiscal shift has not made big improvements to South Africa’s health. Many critical health indicators, such as <a href="http://apps.who.int/gho/data/view.main.200">infant mortality rates</a> and <a href="http://apps.who.int/gho/data/node.main.3?lang=en">life expectancy</a>, are below those of other middle-income countries that spend much less on health care.</p>
<p>Availability and affordability interventions are largely aimed at achieving universal health access. “Health for all” is one of the goals of South Africa’s <a href="http://www.gov.za/issues/national-development-plan-2030">National Development Plan</a>. It is the main aim of South Africa’s pending major health reform – a <a href="http://www.bowman.co.za/FileBrowser/ContentDocuments/NHI.pdf">national health insurance plan</a>.</p>
<p>The government has taken a supply-focused approach to reducing health inequities – an appropriate approach in view of the extreme polarisation of the country’s private and public healthcare systems. But the focus on availability and affordability has overshadowed an equally critical issue – the demand side of access. In other words, what do people want? Do South African consumers find the public health services acceptable?</p>
<h2>Acceptable levels of service</h2>
<p>About 60% of those who attended public health facilities were satisfied with the service they received, irrespective of their illness, injury or socioeconomic status. However, acceptability is subjective and therefore hard to measure. Differing expectations of service levels, based on prior exposure to private health care, make economically empowered individuals more likely to complain than their less affluent counterparts. This bias could skew the findings of the analysis.</p>
<p>The “very satisfied” responses in the GHS data showed that the poor were apparently more satisfied with services than the more affluent. But because these data are self-reported and subject to bias they should be interpreted with caution. More rigorous analytical techniques and research methods are needed if we are to understand patient satisfaction levels.</p>
<p>Some people preferred to consult a private doctor rather than go to a public health facility. Clearly they opted for what they perceived to be better quality. The validity of this perception is debatable though. It can be argued that public health facilities are better equipped and their staff more experienced than private doctors when it comes to tuberculosis and HIV/AIDS treatment. </p>
<p>Levels of acceptable service could be gauged by complaints in the GHS about dirty facilities and rude staff. This was the subject of less than 15% of the complaints about public health facilities, with incivility being a bigger issue than uncleanliness. </p>
<p>These complaints came more from the affluent than the poor, perhaps implying different expectations about cleanliness and friendliness and different norms for the appropriateness of complaining about a “free” public service.</p>
<h2>The private sector</h2>
<p>More than 95% of the respondents felt public health facilities were affordable. This was expected, as primary health care is free for all and public healthc are is free for children under five and pregnant women. Other public health services are billed according to ability to pay, and certain services are offered free of charge to select groups. </p>
<p>Yet a <a href="http://etd.uwc.ac.za/xmlui/handle/11394/4211">study</a> of the general household survey data showed that public health care is perceived as an inferior good. Even some of the poorest and most marginalised are prepared to spend their own money to see a doctor, although the services of their nearest clinic are virtually free. </p>
<p>While affordability remains an issue, it was not the main reason that stopped people from consulting a healthcare provider when ill or injured. But it was clearly more of a barrier for black people than for white. This highlighted a disturbing public-private split along race lines.</p>
<p>Affordability was the main reason why people did not join a medical aid. A large proportion – irrespective of socio-economic status – still paid personally for health care, albeit very small amounts proportional to household income. Encouragingly, this trend decreased for all race and socioeconomic status groups during the period under review.</p>
<h2>Change is needed</h2>
<p>A multi-dimensional approach to interpreting access to health care has gained traction in recent years. But most of the interventions to improve access remain supply oriented.</p>
<p>Access to public health facilities seems to be fairly equitable and well targeted in terms of affordability. The same cannot be said of availability, and particularly acceptability, which are lagging behind. </p>
<p>The government must continue to increase physical access to health care, especially in rural areas. Public health role-players must use resources efficiently to deliver a high quality service that all consumers will find acceptable. </p>
<p>Failure to do so could undermine health policies designed to achieve “health for all”. Particular attention must be paid to the overlooked and under-researched issue of acceptable levels of service. The current scenario does not bode well for South Africa’s major health reform – the implementation of the national health insurance plan.</p><img src="https://counter.theconversation.com/content/49301/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carmen S. Christian does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The government has put a lot of effort into making health care in South Africa more accessible, but the quality of the service still lags behind.Carmen S. Christian, Lecturer in Economics, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/360772015-01-09T15:40:30Z2015-01-09T15:40:30ZFirst privately-run NHS hospital fails: the marvellous medicine wasn’t so great after all<p>Healthcare group Circle <a href="http://www.theguardian.com/society/2015/jan/09/circle-exit-private-contract-hinchingbrooke-nhs">has announced</a> that it plans to withdraw from its contract to run Hinchingbrooke Hospital in Cambridgeshire, three years into a deal that was supposed to last ten years. The company blames the A&E crisis, the payment tariff for acute care, the <a href="http://www.hsj.co.uk/news/exclusive-hinchingbrooke-threatened-with-enforcement-action-by-cqc/5075341.article">Care Quality Commission</a> and its forthcoming critical report on the hospital – and probably the weather and local traffic congestion as well. </p>
<h2>Beyond the PR fluff</h2>
<p>Circle’s <a href="http://www.circlepartnership.co.uk/about-circle/media/a-statement-on-hinchingbrooke">announcement</a> looks cynically timed to use the <a href="http://www.ft.com/cms/s/0/8b3cbca2-9684-11e4-a83c-00144feabdc0.html">current problems</a> in the NHS as an excuse to exit what has been, from the outset, an albatross around its neck. Despite a welter of <a href="http://www.circlepartnership.co.uk/about-circle/media/hinchingbrooke-hospital-named-%22best-trust-in-england-for-quality-of-care%22">positive marketing hype</a> about what a wonderful job it had been doing and how it has transformed a “basket case” hospital into “one of the best hospitals in the UK,” the truth has been that from day one a loss-making and probably unviable NHS acute hospital has still struggled to survive under private control. </p>
<p>In fact, Circle has run up £5m in losses on the contract so far, and that is the threshold at which a break clause allows it to exit early without penalty. I think the prospect of even more financial losses for its shareholders is the real reason for the company pulling out now. </p>
<h2>The cheerleaders</h2>
<p>Some <a href="http://www.ft.com/cms/s/0/2973870a-1daf-11e0-aa88-00144feab49a.html">newspapers</a> and <a href="http://www.dailymail.co.uk/health/article-2059674/Failing-Hinchingbrooke-hospital-taken-private-firm-time-history.html">politicians</a> have been eager cheerleaders for Circle and its supposedly innovative staff-mutual ownership model (it seems to me to be a pretty conventional venture capital-funded outfit dressed up as a social enterprise). They have lauded its leadership and bought the marketing hype, and by extension argued that the best way to improve performance in the NHS <a href="http://www.thetimes.co.uk/tto/health/news/article3222147.ece">might be</a> to give whole tracts of it the Circle medicine treatment – private sector management, commercial acumen, robust financial control and so on. That case looks rather dodgy now the one privately-run NHS acute hospital has fallen by the wayside.</p>
<p>Circle seems to have done some things right at Hinchingbrooke. It engaged clinical staff, particularly doctors, in leading the organisation. It focused on service improvement and transformation, and on the quality of care. But those are all things you can see being done, any day of the week, by <a href="https://theconversation.com/nhs-staff-do-a-fantastic-job-its-time-we-gave-them-more-credit-20804">lots of good NHS organisations</a>.</p>
<h2>What it tells us</h2>
<p>There is nothing magic about the private sector which makes axiomatically better (or worse) at running things than the public sector. On both sides of this polarised debate the ideologues chanting “two legs bad, four legs good” or vice versa tend to drown out more reasoned voices, and the research evidence. That <a href="http://teamgrant.ca/M-THAC%20Greatest%20Hits/Bonus%20Tracks/Delivering%20Health%20Care%20Services.pdf">evidence suggests</a> rather prosaically that it’s not whether you are a private or public sector management team that matters, it’s how good you are at management.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/68580/original/image-20150109-23786-t969ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/68580/original/image-20150109-23786-t969ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/68580/original/image-20150109-23786-t969ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/68580/original/image-20150109-23786-t969ie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/68580/original/image-20150109-23786-t969ie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/68580/original/image-20150109-23786-t969ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/68580/original/image-20150109-23786-t969ie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/68580/original/image-20150109-23786-t969ie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Ideology crowds out sensible discussion about healthcare.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&searchterm=private%20NHS&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=149278940">Ed Samuel</a></span>
</figcaption>
</figure>
<p>For the people of Cambridgeshire, the future of Hinchingbrooke Hospital now looks, paradoxically, quite good. In the short term, the Department of Health and the NHS Trust Development Authority are forced to bail it out, and take it off Circle’s hands. In the longer term, the new chief executive of NHS England, Simon Stevens, has already made it clear that he thinks the acute care sector is already too centralised, and that the way funding is distributed and staffing is organised needs to change to give district general hospitals like Hinchingbrooke a sustainable future. So as Circle pulls out, another chapter for the hospital begins.</p><img src="https://counter.theconversation.com/content/36077/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kieran Walshe does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Healthcare group Circle has announced that it plans to withdraw from its contract to run Hinchingbrooke Hospital in Cambridgeshire, three years into a deal that was supposed to last ten years. The company…Kieran Walshe, Professor of Health Policy and Management, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.