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Nguyen MP, Tariq A, Hinchcliff R, Luu HN, Dunne MP. Contribution of private health services to universal health coverage in low and middle-income countries: Factors affecting the use of private over public health services in Vietnam. Int J Health Plann Manage 2023; 38:1613-1628. [PMID: 37485548 DOI: 10.1002/hpm.3689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/27/2023] [Accepted: 07/09/2023] [Indexed: 07/25/2023] Open
Abstract
The private sector's contribution to Universal health coverage (UHC) has been increasingly recognised by policymakers in low- and middle-income countries. This study aimed to identify service-provider and consumer-level factors affecting choice of private over public health services in Vietnam. A concurrent mixed-method design was adopted. A quantitative phase explored consumers' health service choice by analysing data from a random national sample of 10,354 individuals aged 16 and over. The qualitative phase investigated how private and public providers organise their services to influence consumer choices by conducting interviews with policymakers, hospital and clinic managers, and health practitioners. The combined results demonstrate that at the individual level, absence of any type of health insurance was the factor most closely associated with the use of private services. Private health services were more likely to be used by people from ethnic majority groups compared to ethnic minorities (odds ratio [OR]: 1.6, 95% CI: 1.4-2.0), and by people living in urban compared to rural areas (OR: 1.1, 95% CI: 1.0-1.3). The service providers suggested that consumers opted for private services that were perceived to have poorer quality in the public sector, such as counselling, physical therapy and rehabilitative care. Additional motivational factors include the private sector's more flexible working hours, shorter waiting times, flexible pricing of services, personalised care and better staff behaviour. The findings can inform national health system planning and coordination activities in Vietnam and other countries that aim to harness the attributes of both the public and private sectors to achieve UHC.
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Affiliation(s)
- Mai P Nguyen
- Department of Medical Services Administration, Ministry of Health, Hanoi, Vietnam
- School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Amina Tariq
- School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Reece Hinchcliff
- School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Applied Psychology, Griffith Health Group, Griffith University, Nathan, Queensland, Australia
| | - Hoat N Luu
- Faculty of Medicine, Phenikaa University, Hanoi, Vietnam
| | - Michael P Dunne
- Institute for Community Health Research, Hue University, Hue, Vietnam
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
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Tuvdendorj A, Dechinkhorloo O, Dorjsuren B, Buskens E, Feenstra T. The costs of inappropriate referral pathways in inpatient care for three major noncommunicable diseases in Mongolia: a national registry-based analysis. BMC Health Serv Res 2021; 21:1280. [PMID: 34838017 PMCID: PMC8626993 DOI: 10.1186/s12913-021-07281-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Non-communicable diseases (NCDs) consistently pose a huge economic burden to health systems and countries in general. The aim of this study was to quantify inpatient costs associated with chronic obstructive pulmonary disease, stroke and ischemic heart disease stratified by type of referral pathway, and to investigate key factors that drive these costs. METHODS A registry-based data analysis was performed using national public hospital inpatient records from 2016 to 2018 for 117,600 unique patients and linking patient-level inpatient health care use with hospital-specific unit cost per bed-day. These were combined to calculate the annual inpatient costs for each of the three disorders per person and per year. Generalized linear modeling was used to assess the association of inpatient costs with age, gender, location, comorbidity, treatment referral pathways and years. RESULTS Across three diagnoses, the majority of patients were female. Most were over 50-60 years old, with more than half being a pensioner, typically with at least one comorbidity. About 25% of patients followed what might be considered inappropriate (unofficial) inpatient referral pathways. Mean annual inpatient costs were int$ 721. These costs rose to int$ 849 for unofficial pathways and dropped to int$677 for official pathways. Further covariates significantly associated with high inpatient costs were location, age, gender, and comorbidity. CONCLUSION Our findings provide background information essential to develop evidence-based and cost-effective interventions aimed at health promotion, prevention and service delivery. Reducing the unofficial use of inpatient care can improve efficient resource allocation in health care and prevent further escalation of inpatient costs in the future.
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Affiliation(s)
- Ariuntuya Tuvdendorj
- Department of Health Policy, School of Public Health, Mongolian National University of Medical Sciences, Zorig street, Ulaanbaatar, 14210, Mongolia.
- Department of Epidemiology, Groningen University, University Medical Center Groningen, Groningen, the Netherlands.
| | | | - Bayarsaikhan Dorjsuren
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
| | - Erik Buskens
- Department of Epidemiology, Groningen University, University Medical Center Groningen, Groningen, the Netherlands
| | - Talitha Feenstra
- Department of Epidemiology, Groningen University, University Medical Center Groningen, Groningen, the Netherlands
- Groningen University, Groningen Research Institute of Pharmacy, Groningen, the Netherlands
- Centre for Nutrition, Prevention and Health Services, Institute for Public Health and the Environment, Bilthoven, the Netherlands
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Dorjdagva J, Batbaatar E, Svensson M, Dorjsuren B, Togtmol M, Kauhanen J. Does social health insurance prevent financial hardship in Mongolia? Inpatient care: A case in point. PLoS One 2021; 16:e0248518. [PMID: 33788865 PMCID: PMC8011747 DOI: 10.1371/journal.pone.0248518] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 02/27/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Protecting people from financial hardship and impoverishment due to health care costs is one of the fundamental purposes of the Mongolian health system. However, the inefficient, oversized hospital sector is considered one of the main shortcomings of the system. The aim of this study is to contribute to policy discussions by estimating the extent of catastrophic health expenditure and impoverishment due to inpatient care at secondary-level and tertiary-level public hospitals and private hospitals. METHODS Data were derived from a nationally representative survey, the Household Socio-Economic Survey 2012, conducted by the National Statistical Office of Mongolia. A total of 12,685 households were involved in the study. "Catastrophic health expenditure" is defined as out-of-pocket payments for inpatient care that exceed a threshold of 40% of households' non-discretionary expenditure. The "impoverishment" effect of out-of-pocket payments for inpatient care was estimated as the difference between the poverty level before health care payments and the poverty level after these payments. RESULTS At the threshold of 40% of capacity to pay, 0.31%, 0.07%, and 0.02% of Mongolian households suffered financially as a result of their member(s) staying in tertiary-level and secondary-level public hospitals and private hospitals respectively. About 0.13% of the total Mongolian population was impoverished owing to out-of-pocket payments for inpatient care at tertiary-level hospitals. Out-of-pocket payments for inpatient care at secondary-level hospitals and private hospitals were responsible for 0.10% and 0.09% respectively of the total population being pushed into poverty. CONCLUSIONS Although most inpatient care at public hospitals is covered by the social health insurance benefit package, patients who utilized inpatient care at tertiary-level public hospitals were more likely to push their households into financial hardship and poverty than the inpatients at private hospitals. Improving the hospital sector's efficiency and financial protection for inpatients would be a crucial means of attaining universal health coverage in Mongolia.
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Affiliation(s)
- Javkhlanbayar Dorjdagva
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Enkhjargal Batbaatar
- Department of Social Sciences, Faculty of Social Sciences and Business Studies, University of Eastern Finland, Kuopio, Finland
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | | | - Jussi Kauhanen
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Amgalan N, Shin JS, Lee SH, Badamdorj O, Ravjir O, Yoon HB. The socio-economic transition and health professions education in Mongolia: a qualitative study. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:16. [PMID: 33678178 PMCID: PMC7938553 DOI: 10.1186/s12962-021-00269-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 02/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background Former socialist countries have undergone a socio-economic transition in recent decades. New challenges for the healthcare system have arisen in the transition economy, leading to demands for better management and development of the health professions. However, few studies have explored the effects of this transition on health professions education. Thus, we investigated the effects of the socio-economic transition on the health professions education system in Mongolia, a transition economy country, and to identify changes in requirements. Methods We used a multi-level perspective to explore the effects of the transition, including the input, process, and output levels of the health professions education system. The input level refers to planning and management, the process level refers to the actual delivery of educational services, and the output level refers to issues related to the health professionals, produced by the system. This study utilized a qualitative research design, including document review and interviews with local representatives. Content analysis and the constant comparative method were used for data analysis. Results We explored tensions in the three levels of the health professions education system. First, medical schools attained academic authority for planning and management without proper regulation and financial support. The government sets tuition fees, which are the only financial resource of medical schools; thus, medical schools attempt to enroll more students in order to adapt to the market environment. Second, the quality of educational services varies across institutions due to the absence of a core curriculum and differences in the learning environment. After the transition, the number of private medical schools rapidly increased without quality control, while hospitals started their own specialized training programs. Third, health professionals are struggling to maintain their professional values and development in the market environment. Fixed salaries lead to a lack of motivation, and quality evaluation measures more likely reflect government control than quality improvement. Conclusions Mongolia continues to face the consequences of the socio-economic transition. Medical schools’ lack of financial authority, the varying quality of educational services, and poor professional development are the major adverse effects. Finding external financial support, developing a core curriculum, and reforming a payment system are recommended.
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Affiliation(s)
- Nomin Amgalan
- Department of Medical Education, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Jwa-Seop Shin
- Department of Medical Education, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Seung-Hee Lee
- Department of Medical Education, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Oyungoo Badamdorj
- Division of Educational Policy and Management, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Oyungerel Ravjir
- Department of Infectious Diseases, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Hyun Bae Yoon
- Office of Medical Education, Seoul National University College of Medicine, Seoul, Korea.
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Batbold O, Pu C. Willingness to pay for private health insurance among workers with mandatory social health insurance in Mongolia. Int J Equity Health 2021; 20:7. [PMID: 33407534 PMCID: PMC7789419 DOI: 10.1186/s12939-020-01343-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/01/2020] [Indexed: 11/06/2022] Open
Abstract
Background High out-of-pocket health expenditure is a common problem in developing countries. The employed population, rather than the general population, can be considered the main contributor to healthcare financing in many developing countries. We investigated the feasibility of a parallel private health insurance package for the working population in Ulaanbaatar as a means toward universal health coverage in Mongolia. Methods This cross-sectional study used a purposive sampling method to collect primary data from workers in public and primary sectors in Ulaanbaatar. Willingness to pay (WTP) was evaluated using a contingent valuation method and a double-bounded dichotomous choice elicitation questionnaire. A final sample of 1657 workers was analyzed. Perceptions of current social health insurance were evaluated. To analyze WTP, we performed a 2-part model and computed the full marginal effects using both intensive and extensive margins. Disparities in WTP stratified by industry and gender were analyzed. Results Only < 40% of the participants were satisfied with the current mandatory social health insurance in Mongolia. Low quality of service was a major source of dissatisfaction. The predicted WTP for the parallel private health insurance for men and women was Mongolian Tugrik (₮)16,369 (p < 0.001) and ₮16,661 (p < 0.001), respectively, accounting for approximately 2.4% of the median or 1.7% of the average salary in the country. The highest predicted WTP was found for workers from the education industry (₮22,675, SE = 3346). Income and past or current medical expenditures were significantly associated with WTP. Conclusion To reduce out-of-pocket health expenditure among the working population in Ulaanbaatar, Mongolia, supplementary parallel health insurance is feasible given the predicted WTP. However, given high variations among different industries and sectors, different incentives may be required for participation.
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Affiliation(s)
- Ochirbat Batbold
- Ach Medical University, Peace Avenue-11, Songino-Khairkhan district-18, Ulaanbaatar, Mongolia.,Institute of Public Health, National Yang-Ming University, (112) 155 Linong St. Sec 2, Peitou, Taipei, Taiwan
| | - Christy Pu
- Institute of Public Health, National Yang-Ming University, (112) 155 Linong St. Sec 2, Peitou, Taipei, Taiwan.
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Gautham M, Bruxvoort K, Iles R, Subharwal M, Gupta S, Jain M, Goodman C. Investigating the nature of competition facing private healthcare facilities: the case of maternity care in Uttar Pradesh, India. Health Policy Plan 2019; 34:450-460. [PMID: 31302699 PMCID: PMC6735944 DOI: 10.1093/heapol/czz056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2019] [Indexed: 12/02/2022] Open
Abstract
The private healthcare sector in low- and middle-income countries is increasingly seen as of public health importance, with widespread interest in improving private provider engagement. However, there is relatively little literature providing an in-depth understanding of the operation of private providers. We conducted a mixed methods analysis of the nature of competition faced by private delivery providers in Uttar Pradesh, India, where maternal mortality remains very high. We mapped health facilities in five contrasting districts, surveyed private facilities providing deliveries and conducted in-depth interviews with facility staff, allied providers (e.g. ambulance drivers, pathology laboratories) and other key informants. Over 3800 private facilities were mapped, of which 8% reported providing deliveries, mostly clustered in cities and larger towns. 89% of delivery facilities provided C-sections, but over half were not registered. Facilities were generally small, and the majority were independently owned, mostly by medical doctors and, to a lesser extent, AYUSH (non-biomedical) providers and others without formal qualifications. Recent growth in facility numbers had led to intense competition, particularly among mid-level facilities where customers were more price sensitive. In all facilities, nearly all payment was out-of-pocket, with very low-insurance coverage. Non-price competition was a key feature of the market and included location (preferably on highways or close to government facilities), medical infrastructure, hotel features, staff qualifications and reputation, and marketing. There was heavy reliance on visiting consultants such as obstetricians, surgeons and anaesthetists, and payment of hefty commission payments to agents who brought clients to the facility, for both new patients and those transferring from public facilities. Building on these insights, strategies for private sector engagement could include a foundation of universal facility registration, adaptation of accreditation schemes to lower-level facilities, improved third-party payment mechanisms and strategic purchasing, and enhanced patient information on facility availability, costs and quality.
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Affiliation(s)
- Meenakshi Gautham
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK
| | - Katia Bruxvoort
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK.,Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, Pasadena, CA, USA
| | - Richard Iles
- School of Economic Sciences, Washington State University, Pullman, WA, USA
| | - Manish Subharwal
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Sanjay Gupta
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Manish Jain
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Catherine Goodman
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK
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Tsevelvaanchig U, Narula IS, Gouda H, Hill PS. Regulating the for-profit private healthcare providers towards universal health coverage: A qualitative study of legal and organizational framework in Mongolia. Int J Health Plann Manage 2017; 33:185-201. [PMID: 28556509 DOI: 10.1002/hpm.2417] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/11/2017] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Regulating the behavior of private providers in the context of mixed health systems has become increasingly important and challenging in many developing countries moving towards universal health coverage including Mongolia. This study examines the current regulatory architecture for private healthcare in Mongolia exploring its role for improving accessibility, affordability, and quality of private care and identifies gaps in policy design and implementation. METHODS Qualitative research methods were used including documentary review, analysis, and in-depth interviews with 45 representatives of key actors involved in and affected by regulations in Mongolia's mixed health system, along with long-term participant observation. RESULTS There has been extensive legal documentation developed regulating private healthcare, with specific organizations assigned to conduct health regulations and inspections. However, the regulatory architecture for healthcare in Mongolia is not optimally designed to improve affordability and quality of private care. This is not limited only to private care: important regulatory functions targeted to quality of care do not exist at the national level. The imprecise content and details of regulations in laws inviting increased political interference, governance issues, unclear roles, and responsibilities of different government regulatory bodies have contributed to failures in implementation of existing regulations.
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Affiliation(s)
| | - Indermohan S Narula
- Department of Health Policy and Management, Health Policy Research Center, School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Hebe Gouda
- School of Public Health, University of Queensland, Herston, Queensland, Australia
| | - Peter S Hill
- School of Public Health, University of Queensland, Herston, Queensland, Australia
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