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The Public/Private Sector Mix in Healthcare Delivery: A Comparative Study
Abstract
This volume examines the public/private sector mix in a number of national healthcare systems and their interface with the goals of health equity and quality of healthcare. Moreover, there is a consideration of public accountability. The unique significance of this collection of national studies involving the public/private sector mix of healthcare services and/or finances is that it provides insights into the factors that enhance the public/private sector mix in fulfilling the goals of health equity and the quality of healthcare services as well as an understanding of the circumstances in which elements of the public/private sector mix may be harmful for the achievement of such goals in a variety of national settings. The contributions to this volume provide a variety of perspectives for dealing with these objectives.
... This framework, however, misses the nuanced ways that public and private elements of the system interface and interact. Figure 1 50 improves the 2×2 framework, but still fails to capture other important dimensions, such as distinguishing between services covered and not covered by the Canada Health Act, corporatisation, investor-ownership, out-of-pocket payments (eg, user fees) and private insurance. This illustrates the need for a more nuanced conceptual framework. ...
Introduction
Privatisation through the expansion of private payment and investor-owned corporate healthcare delivery in Canada raises potential conflicts with equity principles on which Medicare (Canadian public health insurance) is founded. Some cases of privatisation are widely recognised, while others are evolving and more hidden, and their extent differs across provinces and territories likely due in part to variability in policies governing private payment (out-of-pocket payments and private insurance) and delivery.
Methods and analysis
This pan-Canadian knowledge mobilisation project will collect, classify, analyse and interpret data about investor-owned privatisation of healthcare financing and delivery systems in Canada. Learnings from the project will be used to develop, test and refine a new conceptual framework that will describe public-private interfaces operating within Canada’s healthcare system. In Phase I, we will conduct an environmental scan to: (1) document core policies that underpin public-private interfaces; and (2) describe new or emerging forms of investor-owned privatisation (‘cases’). We will analyse data from the scan and use inductive content analysis with a pragmatic approach. In Phase II, we will convene a virtual policy workshop with subject matter experts to refine the findings from the environmental scan and, using an adapted James Lind Alliance Delphi process, prioritise health system sectors and/or services in need of in-depth research on the impacts of private financing and investor-owned delivery.
Ethics and dissemination
We have obtained approval from the research ethics boards at Simon Fraser University, University of British Columbia and University of Victoria through Research Ethics British Columbia (H23-00612). Participants will provide written informed consent. In addition to traditional academic publications, study results will be summarised in a policy report and a series of targeted policy briefs distributed to workshop participants and decision/policymaking organisations across Canada. The prioritised list of cases will form the basis for future research projects that will investigate the impacts of investor-owned privatisation.
This study presents the health reform in Uruguay as an example of a country successfully gaining control over health policy and scaling up toward universal health coverage through a national insurance model. The study looks at the circumstances leading to the opening of the policy window and to the politics that made the passage of the reform possible. Evidence is mainly qualitative. The main findings relate to the role the state can play as an intelligent regulator and coordinator; the trade-off facing the governments since consolidating the private and third sector providers can strengthen the opposition to future policy changes; how medical and economic interests do not oppose reforms that preserve their autonomy, and how trade unions will not oppose reforms that simultaneously improve investment and working conditions in the public provider.
This special issue of the Journal is devoted to understanding the many roads that lead toward achieving health equity. The eleven articles in the issue portray an America that is struggling with the clash between its historical ideal of pursuing equality for all and its ambivalence toward achieving equity in all social domains, especially health. Organized in five sections, the issue contains articles that examine and analyze: the role of civil rights law and the courts in shaping health equity; the political discourse that has framed our understanding of health equity; health policies that affect health equity, such as the Medicaid program, as well as related strategies that might help to improve equity, such as the use of mobile technologies to empower individuals; immigration policies and practices that impact health equity in marginalized populations; and commentaries in the final section that explore how the Affordable Care Act has addressed health equity, how repeal of the law would jeopardize equity gains, and how the political discourse and culture of the Trump administration could adversely affect health equity.
This paper reviews and analyzes the implication of the public-private mix of financing and delivery of health care in Canada for lower-income Canadians. Based on the type of government stewardship and the degree of state intervention, the Canadian health system can be separated into three distinct layers: universal hospital and physician services financed and regulated by federal and provincial governments (“Medicare”); mixed services, including prescription drugs and long-term care, subject to some provincial stewardship and subsidy; and privately funded and delivered services such as dental care. Within Medicare financial barriers to access have been removed; however, there is a growing trend toward private sector involvement in the delivery of services, and inequalities by income in the use of physician services are high in Canada relative to other high income countries. Moreover, the exclusion of prescription drugs and long-term care from universal health coverage in Canada, as well as the nearly exclusively private dental market, has created significant access issues for lower-income Canadians.
This Handbook chapter aims to describe and explain the course of reform in North American healthcare from the Great Depression of the 1930s to the years 2013–2014. First, there is a brief discussion of the place of such a compari- son in the broader field of comparative policy studies. Our approach, which follows a ‘close comparison’ mode of analysis, takes up in turn the decades of dispute over the proper role of government in the financing of healthcare services to its citizens. That history constitutes the bulk of the comparative nar- rative, but is supplemented by two additional elements: a case study of the role of courts in North American healthcare reform, and an extended discussion of the role of political institutions in explaining policy change and continuity more generally.
Overview of the social constructions and policy design framework
Several European countries have considered introducing choice of public or private health insurance - usually by allowing people to ‘opt out’ of the statutory scheme - under the assumption that enhancing consumer choice and stimulating competition between insurers will be beneficial. This article examines the impact of opting out on equity and efficiency in European health systems. Focusing on Germany and the Netherlands - the only European countries where this type of choice has been available to significant population groups for a prolonged period (from 1970 to the present day in Germany, and from 1941 to 1986 in the Netherlands) - the analysis suggests that current policy debates may overstate the potential benefits of opting out. Due to market failures in health insurance and differences in the regulatory frameworks governing public and private insurers, choice of public or private coverage creates strong incentives for private insurers to select risks and leads to risk segmentation, thereby breaching equity in funding health care, heightening the financial risk borne by public insurers and lowering incentives for private insurers to operate efficiently. Measures can be taken to correct these negative effects, but some forms of regulation may be politically and technically difficult to implement.
The main point of this article is to explore the methodological questions raised by weaknesses in international comparative work in the field of health policy. The core question is how competent learning from one nation to another can take place. The article argues that there is a considerable gap between the promise and the actual performance of comparative policy studies. Misdescription and superficiality are all too common. unwarranted inferences, rhetorical distortion, and caricatures - all show up too regularly in comparative health policy scholarship and debates. The article first describes the context of the health and welfare state reform debates during the past three decades. In almost all industrialized democracies, rising medical expenditures exacerbated fiscal concerns about the affordability of the mature welfare states. In reaction to pressure for policy change in health care, policy makers looked abroad for promising solutions of domestic problems. The following section takes up the topic of cross-national policy leaning. Then, it critically reviews recent debates about health care reforms and addresses the purposes, promises and pitfalls of comparative study in health policy. The next section categorizes existing comparative health policy literature to highlight the character, possibilities and limits of such work. The concluding section returns to the basic theme: the real promise of comparative scholarship and the quite mixed performance to date.
Why have some developing country states been more successful at facilitating industrialization than others? An answer to this question is developed by focusing both on patterns of state construction and intervention aimed at promoting industrialization. Four countries are analyzed in detail - South Korea, Brazil, India, and Nigeria - over the twentieth century. The states in these countries varied from cohesive-capitalist (mainly in Korea), through fragmented-multiclass (mainly in India), to neo-patrimonial (mainly in Nigeria). It is argued that cohesive-capitalist states have been most effective at promoting industrialization and neo-patrimonial states the least. The performance of fragmented-multiclass states falls somewhere in the middle. After explaining in detail as to why this should be so, the study traces the origins of these different state types historically, emphasizing the role of different types of colonialisms in the process of state construction in the developing world.
This research contribution presents a diagnosis of the health reform experience of six small and mid-sized industrial democracies: Chile, Israel, Singapore, Switzerland, Taiwan and The Netherlands during the last decades of the twentieth century. It addresses the following questions: Why have these six countries, facing similar pressures to reform their health care systems, with similar options for government action, chosen very different pathways to restructure their health care? What did they do? And what happened after the implementation of those reforms? The article describes the current arrangements for funding, contracting and payment, ownership and administration (or “governance”) of health care at the beginning of the 21st century, the origins of the health care reforms, the discussion and choice of policy options, processes of implementation and “after reform adjustments”. The article looks at factors that help explain the variety in reform paths, such as national politics, dominant cultural orientations and the positions of major stakeholders.
This paper defines quality of health care. We suggest that there are two principal dimensions of quality of care for individual patients; access and effectiveness. In essence, do users get the care they need, and is the care effective when they get it? Within effectiveness, we define two key components--effectiveness of clinical care and effectiveness of inter-personal care. These elements are discussed in terms of the structure of the health care system, processes of care, and outcomes resulting from care. The framework relates quality of care to individual patients and we suggest that quality of care is a concept that is at its most meaningful when applied to the individual user of health care. However, care for individuals must placed in the context of providing health care for populations which introduces additional notions of equity and efficiency. We show how this framework can be of practical value by applying the concepts to a set of quality indicators contained within the UK National Performance Assessment Framework and to a set of widely used indicators in the US (HEDIS). In so doing we emphasise the differences between US and UK measures of quality. Using a conceptual framework to describe the totality of quality of care shows which aspects of care any set of quality indicators actually includes and measures and, and which are not included.
To help clarify the confusing debate concerning the public-private divide in Canada and the respective positions of the Romanow and Kirby reports, a new approach is proposed. The funding, administration and delivery of the healthcare "system" is split into distinct analytical categories and then applied to three major coverage groupings: universal public (Canada Health Act) coverage for medically necessary/required services; mixed coverage for drug care, home and long-term care; and private health goods and services. While there were no fundamental differences between Romanow and Kirby concerning the funding of public healthcare in Canada, there were some important differences on issues of administration. In particular, the Romanow report recommended that home mental healthcare services become universally covered under the Canada Health Act as well as fundamental changes to the regulation and administration of prescription drug care. The reports also differed in terms of framing the private delivery question, with the Romanow report questioning whether the evidence justified private-for-profit delivery replacing current private not-for-profit or public arm's length delivery modes.
In January 2021, the incoming Biden administration will inherit urgent priorities to curb health care spending and expand health care coverage to millions of Americans while also addressing the COVID-19 pandemic and resulting economic downturn. Among these competing priorities is the issue of access to and affordability of prescription drugs. Here, we outline Biden’s plan to directly lower prescription drug spending for payers and patients and to expand access to prescription medications through improved health insurance coverage. These policies could provide important financial protections for Americans against high prescription drug prices. Despite widespread public support for addressing prescription drug prices, many of Biden’s plans rely on Congressional action, which will be complicated by the narrow majority held by Democrats in the House and an evenly divided Senate. However, there may be other opportunities to reduce prescription drug spending and improve health insurance enrollment among the uninsured. While directly lowering drug prices would provide the most widespread savings for payers and patients alike, any successful effort to increase the number of Americans enrolled in health insurance or render it more affordable will still likely effectively lower patients’ out-of-pocket costs and improve access to prescription drugs.
The aim of this work is to investigate which policy tools are used in the governance of the healthcare sector. In particular, we compare the healthcare systems of five OECD countries: Australia, Canada, Germany, England and the Netherlands. The analysis intends to reconstruct the healthcare governance methods implemented in these countries, and understand how they have evolved over the last thirty years. Throughout this work, policy tools are subdivided into four categories: direct provision, regulation, financing and information. Direct provision remains the prevailing mode of governance in the English healthcare system. All of the five countries studied in this work make extensive use of regulation. Insurer regulation is particularly stringent in Germany, the Netherlands and Australia. Of the countries examined, those that make the greatest use of financial leverage seem to be Australia and Canada. England and the Netherlands are the two countries that focus most on informative policy tools.
Context: The authors examined whether participation in the Affordable Care Act (ACA) differed by political partisanship. Answering this question is important for understanding how contentious elite-level decision making and discourse may affect policy uptake, and the ability of the ACA to create a constituency of beneficiaries invested in its support.
Methods: The authors combined county- and individual-level data on health insurance gains, political partisanship, and variation in the ACA's implementation to test whether Democratic areas and individuals are more likely to gain health insurance after implementation of the ACA.
Findings: While there was some evidence that Democrats experienced larger insurance gains than Republicans, the major partisan divide was in how insurance was obtained: Democrats were more likely than Republicans to enroll in private marketplace plans, but there were no partisan differences in uptake among those gaining insurance via the Medicaid expansions.
Conclusions: These results provide some important context for the well-known and persistent partisan divide in support for the ACA, an attitudinal divide whose reflection in program participation appears conditional on the salience of different aspects of the ACA.
This article presents a way of understanding the linkage of expert and public opinion through a focus on policy narratives, which serve as deliberately crafted rhetorical bridges between expert discourses and broader cultural experiences. Across advanced nations, the dynamics of this bridging function has differed in different phases of policy development (such as welfare-state establishment, retrenchment, and redesign), depending on the state of discourse in each realm. In the establishment phase in which most programs of universal health care coverage were adopted, expert discourses were relatively synchronized with but subservient to broader policy narratives about collective and individual rights and responsibilities. The United States, in contrast, pursued its final sprint toward universal coverage in a later phase, in which the policy analysis community had greatly expanded and expert discourses had evolved to focus on specialized issues of system redesign. The resulting highly complex technical design did not readily align with an epic narrative of public purpose. Advocates instead relied principally on two narrative lines: an aggregation of anecdotes that was vulnerable to the simpler opposition narrative of an overweening state, and a crusade narrative that met the opposing narrative of patriotic resistance on its own terms but could not allay partisan polarization.
Although the United States spends 16 percent of its gross domestic product on health care, more than 46 million people have no insurance coverage, while one in four Americans report difficulty paying for medical care. Indeed, the U.S. health care system, despite being the most expensive health care system in the world, ranked thirty-seventh in a comprehensive World Health Organization report. With health care spending only expected to increase, Americans are again debating new ideas for expanding coverage and cutting costs. According to the historian Paul V. Dutton, Americans should look to France, whose health care system captured the World Health Organization’s number-one spot. In Differential Diagnoses, Dutton debunks a common misconception among Americans that European health care systems are essentially similar to each other and vastly different from U.S. health care. In fact, the Americans and the French both distrust “socialized medicine." Both peoples cherish patient choice, independent physicians, medical practice freedoms, and private insurers in a qualitatively different way than the Canadians, the British, and many others. The United States and France have struggled with the same ideals of liberty and equality, but one country followed a path that led to universal health insurance; the other embraced private insurers and has only guaranteed coverage for the elderly and the very poor. How has France reconciled the competing ideals of individual liberty and social equality to assure universal coverage while protecting patient and practitioner freedoms? What can Americans learn from the French experience, and what can the French learn from the U.S. example? Differential Diagnoses answers these questions by comparing how employers, labor unions, insurers, political groups, the state, and medical professionals have shaped their nations’ health care systems from the early years of the twentieth century to the present day.
Both public and private providers deliver health services, each with their partic- ular virtues and liabilities. While private healthcare predates public provision, many governments across the world have undertaken some or even all of the responsibility for financing and delivering health services, either at subsidized rates or free of cost at the point of utilization. Given systemic deficiencies in government health programmes as well as the spiralling costs of an expensive, inequitable, and often unregulated private sector, the concept of public-private partnerships (PPPs) has emerged as a policy option in which the healthcare needs of people could be met more effectively if both sectors worked together.
International sources of health statistics overwhelmingly report national average performance. And many international statements about health policy - including the Millennium Development Goals (MDGs) — are formulated in those terms (MDGR, 2013). Yet, in almost all nations there are subgroups who are noticeably less well-off both in their utilization of healthcare services and in their health status. And in recent years, those concerned with healthcare rights (Daniels, 2008) and the movement towards Universal Health Coverage (Rodin and de Ferranti, 2012) have called attention to such disparities and urged governments to act to decrease such differences.
The private sphere has always been an important component in US healthcare entitlements. Since the ACA further embeds the role of private actors, how private actors make claims on the state, and how the state reacts to these claims, becomes even more important, because such claims significantly shape US healthcare entitlements. The extent and increase of private benefits and contracting with private health plans is explicated for each healthcare entitlement program. The politics of how private inclusion shapes healthcare entitlements is examined with three main implications: it (1) creates a dominant discourse of health care deficits and spending crises; (2) submerges the role of government and may diminish mobilization for claiming entitlements; and (3) reduces equity in the distribution of costs and benefits. I conclude by highlighting that there are simple policy designs to address these problems, but the political dynamics of private inclusion will likely work against such policy logics.
This is the final report of the Royal Commission on the Future of Health Care in Canada, first appointed by the Government of Canada on April 3, 2001.Taken together, the 47 recommendations contained in this report serve as a roadmap for a collective journey by Canadians to reform and renew their health care system. They outline actions that must be taken in 10 critical areas, starting by renewing the foundations of universal medicare in Canada.
"Health disparities" and "health equity" have become increasingly familiar terms in public health, but rarely are they defined explicitly. Ambiguity in the definitions of these terms could lead to misdirection of resources. This article discusses the need for greater clarity about the concepts of health disparities and health equity, proposes definitions, and explains the rationale based on principles from the fields of ethics and human rights.
Critics of legislative delegation to the bureaucracy worry that delegation diminishes electoral accountability and exacerbates legislative shirking. This paper provides equilibrium foundations for such concerns in a model in which legislators are heterogeneous in their policy preferences and bureaucrats have expertise concerning the policies that best serve the public. We further use our model to address debates concerning the welfare consequence of judicial enforcement of the nondelegation doctrine. We find that when the risk of special-interest capture of incumbent legislators is high and bureaucratic expertise is limited, a ban on delegation would benefit our model's representative voter; otherwise, the representative voter gains from delegation despite the fact that it can be exploited by unscrupulous politicians.
Karl Polanyi's 1944 book, The Great Transformation, has been recognized as central for the field of economic sociology, but it has not been subject to the same theoretical scrutiny as other classic works in the field. This is a particular problem in that there are central tensions and complexities in Polanyi's argument. This article suggests that these tensions can be understood as a consequence of Polanyi's changing theoretical orientation. The basic outline of the book was developed in England in the late 1930s when Polanyi was working within a specific type of Marxist framework. However, as he was writing the book, he developed several new concepts, including fictitious commodities and the embedded economy, that led in new directions. Because circumstances did not give him the time to revise his manuscript, the book is marked by a tension between these different moments in his own theoretical development. The result is that Polanyi glimpses the concept of the always embedded market economy, but he does not name it or elaborate it.
The United States spends far more than other countries do on its health care system, but comparative data strongly imply that Americans are not receiving their money's worth. There is much hand-wringing about spending, but little attention is paid to the main culprit: lack of market power by purchasers-something that exists in nearly all other countries. This lack of attention is not surprising, however, given that having an open discussion could ultimately lead to more regulation-and a major redistribution of resources away from providers and back to employers, individuals and families, and taxpayers.
It is tempting to oversell the practical value of applied research. A hard look at the effects of U.S. social science on public policy in areas such as active labor market policies (training, job creation, placement, etc.), crime prevention, fiscal policy, poverty reduction, and health care reform suggests an inverse relationship between social science consensus and policy and budgetary decisions. Fragmented and decentralized political economies (e.g., the United States) foster policy segmentation and isolated, short-run single-issue research--often politicized and misleading. More corporatist democracies (such as Sweden, Norway, Austria, and Germany) evidence a tighter relation between knowledge and power in which a wider range of issues is connected, longer-range effects are sometimes considered, and research is more often actually used for planning and implementation. Even in less hospitable societies, however, social science does make its way in the long run. Favorable conditions and examples are discussed.
In January 1997, the government of Quebec, Canada, implemented a public/private prescription drug program that covered the entire population of the province. Under this program, the public sector collaborates with private insurers to protect all Quebecers from the high cost of drugs. This article outlines the principal features and history of the Quebec plan and draws parallels between the factors that led to its emergence and those that led to the passage of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) in the United States. It also discusses the challenges and similarities of both programs and analyzes Quebec's ten years of experience to identify adjustments that may help U.S. policymakers optimize the MMA.
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