essay on government hospital

Essay on Government Hospital

Students are often asked to write an essay on Government Hospital in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

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100 Words Essay on Government Hospital

Introduction.

Government hospitals are medical facilities run by the state. They provide healthcare services to all, particularly focusing on the underprivileged and those who cannot afford private hospitals.

These hospitals offer a range of services including general medicine, surgery, maternity care, and emergency services. They often have specialized departments like cardiology, neurology, and orthopedics.

The major benefit of government hospitals is their affordability. They provide free or low-cost treatment, making healthcare accessible to everyone.

Despite their benefits, government hospitals face challenges like overcrowding, lack of advanced equipment, and sometimes, shortage of staff.

Government hospitals play a crucial role in society. They need continuous improvement and support to serve the public better.

250 Words Essay on Government Hospital

Government hospitals play a pivotal role in providing healthcare services to the public, especially in developing countries. These institutions, funded by the state, aim to offer affordable and quality healthcare to all, irrespective of their socioeconomic status.

The Significance of Government Hospitals

The importance of government hospitals cannot be overstated. They serve as the primary healthcare providers for the majority of the population, particularly the economically disadvantaged and those residing in remote areas. With their wide reach and subsidized services, they ensure that healthcare is not a privilege but a right for every citizen.

Challenges Faced by Government Hospitals

Despite their noble intentions, government hospitals often grapple with numerous challenges. These include inadequate funding, shortage of skilled medical personnel, and insufficient infrastructure. These issues often translate into long waiting times, compromised patient care, and a general perception of inefficiency.

Improving the Efficacy of Government Hospitals

Addressing these challenges requires a multi-pronged approach. Increasing budgetary allocations for public health, implementing robust recruitment and training programs for medical personnel, and investing in infrastructure development are some of the key steps. Moreover, leveraging technology for better management of resources can significantly enhance the efficiency of these institutions.

In conclusion, government hospitals are instrumental in ensuring that healthcare is accessible and affordable for all. While they face several challenges, strategic planning and investment can significantly improve their performance, thereby strengthening the overall public health system.

500 Words Essay on Government Hospital

Government hospitals are public health facilities primarily funded and managed by the state or national government. They are integral components of a nation’s healthcare system, providing affordable and often free medical services to the public. However, their efficiency and effectiveness have been a subject of debate, underlined by concerns over quality of care, infrastructure, and resource allocation.

Role and Importance of Government Hospitals

Government hospitals play a crucial role in providing healthcare services to the underprivileged and marginalized sections of society. They are often the only accessible healthcare facilities for people living in remote and rural areas. They also serve as training grounds for medical professionals, fostering the development of healthcare skills and expertise.

Despite their importance, government hospitals face numerous challenges. These include inadequate infrastructure, shortage of medical personnel, and insufficient funding. The high patient load often leads to overcrowded wards and long waiting times, compromising the quality of healthcare. Moreover, the lack of advanced medical equipment and technology can limit the scope of treatment options available to patients.

Quality of Care in Government Hospitals

The quality of care in government hospitals is a contentious issue. While some hospitals maintain commendable standards, others fall short due to resource constraints and management inefficiencies. The perception of subpar service in government hospitals has led to a preference for private healthcare among those who can afford it. However, it is essential to note that many government hospitals deliver critical services, including emergency care, childbirth, and disease control, often in challenging circumstances.

Reforms and Improvement Strategies

Addressing the issues plaguing government hospitals requires comprehensive reforms and strategies. These could include increased funding, improved management practices, and the adoption of modern medical technologies. It is also crucial to focus on capacity building to ensure a sufficient number of trained healthcare professionals. Public-private partnerships could be explored as a means to leverage the efficiency of the private sector while ensuring the accessibility and affordability of public healthcare.

In conclusion, government hospitals are an essential part of a nation’s healthcare system, particularly for the underserved sections of society. While they face significant challenges, these can be addressed through strategic reforms and investments. The aim should be to ensure that these hospitals can deliver quality healthcare to all, thereby playing their part in achieving the broader goal of universal health coverage.

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Essay on Hospital

500 words essay on  hospital.

Hospitals are institutions that deal with health care activities. They offer treatment to patients with specialized staff and equipment. In other words, hospitals serve humanity and play a vital role in the social welfare of any society. They have all the facilities to deal with varying diseases to make the patient healthy. The essay on hospital will take us through their types and importance.

Types of Hospitals

Generally, there are two types of hospitals, private hospitals and government hospitals. An individual or group of physicians or organization run private hospitals. On the other hand, the government runs the government hospital.

There are also semi-government hospitals that a private and organization and government-run together. Further, there are general hospitals that deal with different kinds of healthcare but with a limited capacity.

General hospitals treat patients from any type of disease belonging to any sex or age. Alternatively, there are specialized hospitals that limit their services to a particular health condition like oncology, maternity and more.

The main aim of hospitals is to offer maximum health services and ensure care and cure. Further, there are other hospitals also which serve as training centres for the upcoming physicians and offer training to professionals.

Many hospitals also conduct research works for people. The essential services which are available in a hospital include emergency and casualty services, OPD services, IPD services, and operation theatre.

Importance of Hospitals

Hospitals are very important for us as they offer extensive treatment to all. Moreover, they are equipped with medical equipment which helps in the diagnosis and treatment of many types of diseases.

Further, one of the most important functions of hospitals is that they offer multiple healthcare professionals. It is filled with a host of doctors, nurses and interns. When a patient goes to a hospital, many doctors do a routine check-up to ensure maximum care.

Similarly, when there are multiple doctors in one place, you can take as many opinions as you want. Further, you will never be left unattended with the availability of such professionals. It also offers everything under one roof.

For instance, in the absence of hospitals, we would have to go to different places to look for specialist doctors in their respective clinics. This would have just increased the hassle and waste energy and time.

But, hospitals narrow down this search to a great level. Hospitals are also a great source of employment for a large section of society. Apart from the hospital staff, there are maintenance crew, equipment handlers and more.

In addition, they also provide cheaper healthcare as they offer treatment options for patients from underprivileged communities. We also use them to raise awareness regarding different prevention and vaccination drives. Finally, they also offer specialized treatment for a particular illness.

Get the huge list of more than 500 Essay Topics and Ideas

Conclusion of the Essay on Hospital

We have generally associated hospital with illness but the case is the opposite of wellness. In other words, we visit the hospital all sick and leave healthy or better than before. Moreover, hospitals play an essential role in offering consultation services to patients and making the population healthier.

FAQ of Essay on Hospital

Question 1: What is the importance of hospitals?

Answer 1: Hospitals are significant as they treat minor and serious diseases, illnesses and disorders of the body function of varying types and severity. Moreover, they also help in promoting health, giving information on the prevention of illnesses and providing curative services.

Question 2: What are the services of a hospital?

Answer 2: Hospitals provide many services which include short-term hospitalization. Further, it also offers emergency room services and general and speciality surgical services. Moreover, they also offer x-ray and radiology and laboratory services.

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Pros and Cons of Government Healthcare

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Government healthcare refers to government funding of healthcare services via direct payments to doctors, hospitals, and other providers. In the U.S. healthcare system , medical professionals are not employed by the government. Instead, they provide medical and health services privately and are reimbursed by the government for these services, in much the same way that insurance companies reimburse them.

An example of a successful U.S. government healthcare program is Medicare, established in 1965 to provide health insurance for people aged 65 and over or who meet other criteria such as disability.

For many years, the U.S. was the only industrialized country in the world, democratic or non-democratic, without universal healthcare for all citizens provided by government-funded coverage. But in 2009, that changed. Here's everything that happened and why it matters still today.

50 Million Uninsured Americans in 2009

In mid-2009, Congress worked to reform U.S. healthcare insurance coverage, which at that time left more than 50 million men, women, and children uninsured and without access to adequate medical and health services .

This deficit was due to the fact that healthcare coverage for all people, except for some low-income children and those covered by Medicare, was provided only by insurance companies and other private-sector corporations. This made it inaccessible for many Americans.

Private company insurers proved ineffective at controlling costs and providing inclusive care, some actively working to exclude as many people from healthcare coverage as possible.

Explained Ezra Klein for The Washington Post : "The private insurance market is a mess. It's supposed to cover the sick and instead competes to insure the well. It employs platoons of adjusters whose sole job is to get out of paying for needed health care services that members thought were covered," (Klein 2009).

In fact, multi-million bonuses were even awarded annually to top healthcare executives as an incentive to deny coverage to policyholders.

As a result, in the United States pre-2009, more than eight in ten of individuals uninsured were from families living 400% below the Federal Poverty Level. Non-white populations were also disproportionately uninsured; Hispanics had an uninsured rate of 19% and Blacks had a rate of 11% though people of color only made up 43% of the population. Finally, 86% of uninsured individuals were adults not classified as elderly.

In 2007, Slate reported, "The current system is increasingly inaccessible to many poor and lower-middle-class people ... those lucky enough to have coverage are paying steadily more and/or receiving steadily fewer benefits," (Noah 2007).

This widespread issue led to a reform campaign begun by the Democratic party and supported by the president.

Reform Legislation

In mid-2009, things got heated when several coalitions of Congressional Democrats crafted competing healthcare insurance reform legislation. Republicans did not contribute much substantive healthcare reform legislation in 2009.

President Obama voiced support for universal healthcare coverage for all Americans, which would be provided by selecting among various coverage options, including an option for government-funded healthcare or a public plan option.

However, the President stayed safely on the political sidelines at first, forcing Congressional clashes, confusion, and setbacks in delivering on his campaign promise to "make available a new national health plan to all Americans."

Healthcare Packages Under Consideration

Most Democrats in Congress, like the president, supported universal healthcare coverage for all Americans offered through various insurance providers and many coverage options. Many saw a low-cost, government-funded healthcare option as important to include.

Under the multi-option scenario, Americans satisfied with their present insurance could opt to keep their coverage. Americans dissatisfied or without coverage could opt for government-funded coverage.

As this idea spread, Republicans complained that the free-market competition offered by a lower-cost public-sector plan would cause private-sector insurance companies to cut their services, lose customers, and inhibit profitability to the extent that many would be forced to go entirely out of business.

Many progressive liberals and Democrats believed strongly that the only fair, just U.S. healthcare delivery system would be a single-payer system, such as Medicare, in which only low-cost, government-funded healthcare coverage is provided to all Americans on an equal basis. Here's how the public responded to the debate.

Americans Favored a Public Plan Option

According to HuffPost journalist Sam Stein, the majority of people were in support of public healthcare options: "... 76 percent of respondents said it was either 'extremely' or 'quite' important to 'give people a choice of both a public plan administered by the federal government and a private plan for their health insurance,'" (Stein 2009).

Likewise, a New York Times/CBS News poll found that, "The national telephone survey, which was conducted from June 12 to 16, found that 72 percent of those questioned supported a government-administered insurance plan—something like Medicare for those under 65—that would compete for customers with private insurers. Twenty percent said they were opposed," (Sack and Connelly 2009).

History of Government Healthcare

2009 was not the first year that government healthcare was talked about, and Obama was far from the first president to push for it; past presidents had proposed the idea decades before and taken steps in this direction. Democrat Harry Truman, for example, was the first U.S. President to urge Congress to legislate government healthcare coverage for all Americans.

According to Healthcare Reform in America by Michael Kronenfield, President Franklin Roosevelt intended for Social Security to also incorporate healthcare coverage for seniors, but shied away for fear of alienating the American Medical Association.

In 1965, President Lyndon Johnson signed into law the Medicare program, which is a single-payer, government healthcare plan. After signing the bill, President Johnson issued the first Medicare card to former President Harry Truman.

In 1993, President Bill Clinton appointed his wife, well-versed attorney Hillary Clinton , to head a commission charged with forging a massive reform of U.S. healthcare. After major political missteps by the Clintons and an effective, fear-mongering campaign by Republicans, the Clinton healthcare reform package was dead by Fall 1994. The Clinton administration never tried again to overhaul healthcare, and Republican President George Bush was ideologically opposed to all forms of government-funded social services.

Again in 2008, healthcare reform was a top campaign issue among Democratic presidential candidates . Presidential candidate Barack Obama promised that he would "make available a new national health plan to all Americans, including the self-employed and small businesses , to buy affordable health coverage that is similar to the plan available to members of Congress."

Pros of Government Healthcare

Iconic American consumer advocate Ralph Nader summed up the positives of government-funded healthcare from the patient's perspective:

• Free choice of doctor and hospital;
• No bills, no co-pays, no deductibles;
• No exclusions for pre-existing conditions; you are insured from the day you are born;
• No bankruptcies due to medical bills;
• No deaths due to lack of health insurance;
• Cheaper. Simpler. More affordable;
• Everybody in. Nobody out;
• Save taxpayers billions a year in bloated corporate administrative and executive compensation costs, (Nader 2009).

Other important positives of government-funded healthcare include:

• 47 millions Americans lacked healthcare insurance coverage as of the 2008 presidential campaign season. Soaring unemployment since then caused the ranks of the uninsured to swell past 50 million in mid-2009. Mercifully, government-funded healthcare provided access to medical services for all uninsured, and lower costs of government healthcare caused insurance coverage to be significantly more accessible to millions of individuals and businesses.
• Doctors and other medical professionals can now focus on patient care and no longer need to spend hundreds of wasted hours annually dealing with insurance companies. Patients, too, no longer need to fritter inordinate amounts of time haggling with insurance companies.

Cons of Government Healthcare

Conservatives and libertarians generally oppose U.S. government healthcare mainly because they don't believe that it's a proper role of government to provide social services to private citizens. Instead, conservatives believe that healthcare coverage should continue to be provided solely by private-sector, for-profit insurance corporations, or possibly by non-profit entities.

In 2009, a handful of Congressional Republicans suggested that perhaps the uninsured could obtain limited medical services via a voucher system and tax credits for low-income families. Conservatives also contended that lower-cost government healthcare would impose too great of a competitive advantage against for-profit insurers.

The Wall Street Journal argued: "In reality, equal competition between a public plan and private plans would be impossible. The public plan would inexorably crowd out private plans, leading to a single-payer system," (Harrington 2009).

From the patient's perspective, the negatives of government-funded healthcare include:

• A decrease in flexibility for patients to freely choose from a vast cornucopia of drugs, treatment options, and surgical procedures offered today by higher-priced doctors and hospitals.
• Fewer potential doctors may opt to enter the medical profession due to decreased opportunities for high compensation. Fewer doctors, coupled with skyrocketing demand for doctors, could eventually lead to a shortage of medical professionals and to longer waiting periods for appointments.

Healthcare Today

In 2010, the Patient Protection and Affordable Care Act (ACA), often called Obamacare, was signed into law by President Obama. This act provides provisions that make healthcare more affordable such as tax credits to low-income families, expanded Medicaid coverage, and made more types of health insurance available to uninsured consumers at different prices and levels of protection. Government standards have been put in place to ensure that all health insurance covers a set of essential benefits. Medical history and pre-existing conditions are no longer legitimate grounds for denying coverage to anyone.

• Harrington, Scott. "The 'Public Plan' Would Be the Only Plan." The Wall Street Journal , 15 June 2009.
• Klein, Ezra. "Health Care Reform for Beginners: The Many Flavors of the Public Plan." The Washington Post , 2009.
• Kronenfeld, Jennie, and Michael Kronenfeld. Healthcare Reform in America: A Reference Handbook . 2nd ed., ABC-CLIO, 2015.
• Nader, Ralph. "Nader: Obama's Flip-Flop on Single Payer." Single Payer Action, 2009.
• Noah, Timothy. "A Short History of Health Care." Slate , 13 Mar. 2007.
• Sack, Kevin, and Marjorie Connelly. "In Poll, Wide Support for Government-Run Health." The New York Times , 20 June 2009.
• Stein, Sam. "Obama Boost: New Poll Shows 76% Support for Choice of Public Plan." HuffPost , 25 May 2011.
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Types of Hospitals in the United States

There are more than 5000 hospitals in the United States. Patients should look for the right hospital for their needs.

Most hospitals provide medical and surgical care for acute (short-term) illnesses or conditions. The services available to patients can differ across hospital systems and even between hospitals within the same system. Hospitals’ approaches to patient care may differ based on hospital size, staffing, location, resources, and other factors. Because of these differences, it is important that patients and their caregivers understand which hospitals can offer the specific health care services that they need.

Community Hospitals (Nonfederal Acute Care)

Most US hospitals are classified as community hospitals according to the American Hospital Association. Two-thirds are located in large cities. Some community hospitals provide general care, and others focus on certain diseases and conditions, such as orthopedics, to provide specialty care. A general community hospital might also have areas of concentration or expertise, such as trauma and cancer care, that are often verified by accreditation organizations like the American College of Surgeons. Community hospitals can have as few as 6 beds or more than 500 beds.

Community hospitals can also be classified as major teaching, minor teaching, or nonteaching hospitals. Teaching hospitals train future physicians and other health care professionals. They also have ongoing research projects or clinical trials and provide care for patients with rare or complex conditions. Major teaching hospitals, or academic medical centers, may be affiliated with a medical school. Nonteaching hospitals have professionally trained medical staff and focus on providing essential care for patients in a community rather than medical training and research.

Federal Government Hospitals

About 200 hospitals are operated by the federal government in the United States. These hospitals provide care for routine medical and surgical problems for specific patient populations, such as active military personnel. The Department of Defense, the Department of Health and Human Services, and the Veterans Health Administration oversee these hospitals.

Nonfederal Psychiatric Care

More than 400 hospitals exist in the private sector to serve the unique needs of patients with mental health illnesses requiring acute hospital care. These hospitals treat conditions such as severe depression and substance abuse.

Nonfederal Long-term Care

Patients with extreme illness that no longer requires acute care are often referred to a long-term care hospital. These facilities provide medical and rehabilitative care for prolonged periods.

For More Information

Medicare Guide to Choosing a Hospital www.medicare.gov/pubs/pdf/10181-Guide-Choosing-Hospital.pdf

Medicare Checklist for Choosing a Hospital www.medicare.gov/files/hospital-checklist.pdf

American Hospital Association www.aha.org/research/rc/stat-studies/fast-facts.shtml

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Sources: American Hospital Association, Centers for Medicare & Medicaid Services

Howell MD. A 37-year-old man trying to choose a high-quality hospital: review of hospital quality indicators. JAMA . 2009;302(21):2353-2360.

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Liu JB , Kelz RR. Types of Hospitals in the United States. JAMA. 2018;320(10):1074. doi:10.1001/jama.2018.9471

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• Research article
• Open access
• Published: 27 February 2018

Comparing public and private providers: a scoping review of hospital services in Europe

• Liina-Kaisa Tynkkynen 1 &
• Karsten Vrangbæk 2  

BMC Health Services Research volume  18 , Article number:  141 ( 2018 ) Cite this article

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What is common to many healthcare systems is a discussion about the optimal balance between public and private provision. This paper provides a scoping review of research comparing the performance of public and private hospitals in Europe. The purpose is to summarize and compare research findings and to generate questions for further studies.

The review was based on a methodological approach inspired by the British EPPI-Centre’s methodology. This review was broader than review methodologies used by Cochrane and Campbell and included a wider range of methodological designs. The literature search was performed using PubMed, EconLit and Web of Science databases. The search was limited to papers published from 2006 to 2016. The initial searches resulted in 480 studies. The final sample was 24 papers. Of those, 17 discussed economic effects, and seven studies addressed quality.

Our review of the 17 studies representing more than 5500 hospitals across Europe showed that public hospitals are most frequently reported as having the best economic performance compared to private not-for-profit (PNFP) and private for-profit (PFP) hospitals. PNFP hospitals are second, while PFP hospitals are least frequently reported as superior. However, a sizeable number of studies did not find significant differences. In terms of quality, the results are mixed, and it is not possible to draw clear conclusions about the superiority of an ownership type. A few studies analyzed patient selection. They indicated that public hospitals tend to treat patients who are slightly older and have lower socioeconomic status, riskier lifestyles and higher levels of co-morbidity and complications than patients treated in private hospitals.

Conclusions

The paper points to shortcomings in the available studies and argues that future studies are needed to investigate the relationship between contextual circumstances and performance. A big weakness in many studies addressing economic effects is the failure to control for quality and other operational dimensions, which may have influenced the results. This weakness should also be addressed in future comparative studies.

Peer Review reports

Public funding, as well as public provision of healthcare services, has been a key feature of many modern welfare states. However, since the 1980s the realms of the public and private sectors have been redefined in many countries [ 43 ]. At the same time, systems financed through social or private insurance have developed new ways of organizing their relationships with providers. What is common to all healthcare systems is a discussion about the optimal balance between public and private provision.

In a seminal paper from 1963, Kenneth Arrow demonstrated that health care has a number of characteristics that violate the principles of a perfect market [ 3 ]. Healthcare consumers do not have sufficient information to know when and to what extent health care is needed or to compare alternatives. Externalities are not incorporated in decision making, and patients risk catastrophic losses in the event of serious illness. Attempts to solve this problem through private insurance carry other risks in terms of adverse selection and moral hazards. As a consequence, all modern healthcare systems have some degree of public involvement in the regulation, financing or provision of services. The implication is that health care is delivered in highly regulated markets with different combinations of public and private actors [ 7 ]. This leads us to ask whether there is evidence that private delivery organizations perform better than public delivery organizations in regulated health care markets.

We investigated this question by conducting a scoping review of the available evidence from recent studies within the European region. Although this region includes different types of healthcare systems, all countries rely considerably on public or not-for-profit providers in addition to some degree of private for-profit delivery. Focusing on the European region allowed us to include systems that are based on similar values about solidarity, while excluding studies from countries with radically different underlying values, such as the United States (US) and Singapore. At the same time, by including the entire region, we can expand on the degree of diversity and volume compared to previous studies, such as Tiemann et al. [ 50 ].

Our method was a scoping review which aimed to summarize and compare previous studies presenting evidence on differences in performance between public and private hospitals in European healthcare systems. Scoping reviews aim to “map rapidly the key concepts underpinning a research area and the main sources and types of evidence available and can be undertaken as stand-alone projects in their own right” [ 2 ]. The specific purpose of this review was to summarize and compare research findings, to relate the findings to previous reviews and to generate questions for further studies and systematic reviews.

Theoretical perspectives on public–private comparisons

Theoretical claims for positive effects of private ownership typically stem from public choice and property rights theories, which revolve around a competition and a public management/ownership argument, respectively [ 1 , 13 , 21 ]. The competition argument states that although healthcare markets may be imperfect, competition in itself can have beneficial effects. Private providers are forced by competitive pressure to optimize efficiency, while political and administrative pressures are more important for public providers. The lack of competitive pressures means that public managers are unable to measure the efficiency of their organizations against a commercial bottom line. Decisions on resource allocation and survival of the organization are left to public decision makers who cannot rely on market prices to generate an equilibrium between demand and supply.

The public management/ownership argument states that public sector organizations lack incentives to perform efficiently, these organizations often have broad and conflicting objectives, and they have no bankruptcy constraint. That is, they can continue to perform at sub-optimal levels without the risk of going out of business [ 1 ]. Furthermore, public organizations are not accountable to shareholders and owners and therefore, potentially have less external pressure to focus on innovation and technological development. Finally, it has been argued that a major difference between public and private hospitals is that public hospitals tend to operate in settings with “soft budget constraints” [ 22 , 40 ]. Some countries have tried to overcome this difference through various types of purchaser–provider splits [ 7 ] and legislation regarding hard budget constraints such as the Danish “Budget Law.”

Several theoretical contributions have nuanced and broadened the expectations from public choice and property rights theory [ 10 , 53 ]. Transaction cost economics emphasizes the importance of asset specificity and the measurability of the services that are provided in the market [ 15 , 54 ]. Rather than approaching public services as something that would, by definition, be more effectively produced in a private market, transaction cost economics hypothesizes that different service characteristics create more or less favorable conditions for in-house production and contracting [ 29 ]. Economic benefits from contracting are more likely to be realized if the quantity and quality of the services can be unambiguously described and measured. Otherwise, the costs of preparing tenders, evaluating bids, signing contracts and monitoring (and possibly sanctioning) service delivery are likely to be high. The largest economic effects, thus, are expected in technical services characterized by low asset specificity and high measurability, whereas smaller or even negative economic effects would be expected in complex services with high asset specificity and low measurability. For hospitals, this would lead us to expect that standardized procedures, for example, within some surgical areas and technical support functions are more likely to provide privatization benefits than complex services within the field of psychiatry or geriatrics, for instance. Hospitals are complex organizations, which typically include high- and low-specificity services. According to asset specificity theory, this leads to additional uncertainty about the benefits of privatization compared to the competition and ownership argument.

Industrial organization theory stresses a number of factors that make public markets distinct from traditional private markets and thus, create less optimal conditions for contracting out than expected by public choice theory [ 10 ]. According to this perspective, many public services are characterized by natural monopolies and high entrance costs, which limit competition and potentially make highly regulated markets with public providers less efficient than private markets [ 26 ]. Principal-agent theory further emphasizes the problem of information particularly in markets for welfare services, such as health, social and child care, where those buying the service have limited insight into the actual delivery practice of the agents. The presence of information asymmetries can lead to goal displacement and unwanted practices, such as “cream-skimming” (selection of the easiest tasks) and “parking” of the least profitable clients. This can endanger the system-level benefits assumed in perfect market conditions.

Decreasing marginal effects from contracting out suggests that economic effects tend to decrease over time [ 8 , 34 , 35 ]. There are two theoretical claims behind this argument. First, it is likely that rational purchasing organizations begin with contracting out those services and tasks where the largest gains are expected. Once the organizations have harvested the low hanging fruits, we can expect decreasing benefits from additional contracting out [ 9 , 34 ]. Second, involvement of private providers creates competitive pressure on public in-house production units, which may lead to more effective public production [ 5 ]. The market mechanism and exposure to competition, according to this argument, increase the efficiency of not only the contracted services but also the internally produced services [ 9 ]. Once the public providers have adjusted their operational practices, there will be few or no additional gains from switching to private providers.

The focus of this paper was to provide an empirical overview of efficiency results as reported in the empirical studies we identified in our database searches. The studies employed slightly different definitions and techniques (see Table  3 ), but data envelopment analysis (DEA) and stochastic frontiers analysis (SFA) techniques dominate. Technical and allocative efficiency comprises “overall efficiency” [ 33 ]. Technical efficiency is producing the maximum amount of output from a given amount of input or alternatively, producing a given output with minimum input quantities, such that when an organization is technically efficient, it operates on its production frontier. Allocative efficiency occurs when the input mix is that which minimizes cost, given input prices or alternatively, when the output mix is that which maximizes revenue, given output prices.

In addition to efficiency differences, we reviewed evidence of potential quality differences and operational differences between public and privately owned organizations. Operational differences include factors such as patient selection, staff composition and procedures that may include thresholds for admissions. In terms of quality, the measurements used were diverse which made it difficult to draw clear conclusions across the studies. Still, quality and operational parameters are important as they relate to other policy objectives than efficiency. However, very few studies embarked on multidimensional assessments, and narrow efficiency measures were, by far, the most commonly reported dimension.

Setting the stage: The results from previous review studies

We start by summarizing state-of-the-art as presented in previous international review papers that examined differences in economic and/or quality performance between private and public hospital organizations. The review studies were not included in the core sample, as we focused on primary studies published from 2006 to 2016 within the European region. Herrera et al. [ 32 ] provided an overview of systematic reviews of the performance of private for-profit (PFP), private not-for-profit (PNFP) and public healthcare providers. The authors reviewed 5918 references to identify systematic reviews and ended up with nine relevant studies of sufficiently high quality. According to the nine systematic reviews, ownership appears to have an effect on health- and healthcare-related outcomes. In the comparison of PFP and PNFP providers, significant differences in terms of patient mortality and payments to facilities were found; both were higher in PFP facilities. In terms of quality and economic indicators, such as efficiency, there were no significant results. When PNFP and public providers were compared, as well as PFP and public providers, no clear differences were found. The overall conclusion from the study was that PFP providers seem to have poorer results than their PNFP counterparts, but there are still important evidence gaps in the literature that need to be covered.

Currie et al. [ 18 ] reviewed 34 studies. Most of these studies found no difference between PFP and PNFP full-service hospitals in terms of relative costs, quality of care or efficiency. Shen et al. [ 46 ] employed a quantitative method when reviewing 40 studies to identify the factors that explain the different findings for cost, revenue, profit margin and efficiency in the empirical literature. The authors found that variations in the magnitudes of ownership effects could be explained by the research focus and methodology of the individual studies. Studies using empirical methods that controlled for a few confounding factors tended to find larger differences between PFP and PNFP hospitals than studies that controlled for a wider range of confounding factors. Functional form and sample size also matter. Failure to apply log transformation to highly skewed expenditure data yielded misleadingly large estimated differences between PFP hospitals and PNFP hospitals. Studies with fewer than 200 observations also produced larger point estimates and wider confidence intervals. In a follow-up study conducted in 2008 by Egglestone et al., the authors found that pooled estimates of ownership effects are sensitive to the subset of studies included and the extent of overlap among hospitals analyzed in the underlying studies [ 23 ]. Ownership appears to be systematically related to differences in quality among hospitals in several contexts. Whether studies found PFP and public hospitals have higher mortality rates or rates of adverse events than their PNFP counterparts depended on the data sources, time period and region covered.

Tiemann et al. [ 50 ] investigated hospital ownership and efficiency in a review of studies that focused on Germany. The authors concluded that in line with the evidence found in studies from other countries, especially the US, the evidence from Germany suggests that private ownership (i.e., PFP and PNFP) is not necessarily associated with higher efficiency compared to public ownership. Irvin’s [ 36 ] review of studies of U.S. healthcare organizations showed that there is a quality gap between for-profit and nonprofit firms in some healthcare sectors (long-term care and mental health), depending on the prevailing type of financial payment for health care.

Hollingsworth [ 33 ] reviewed 317 studies published until 2006. He concluded cautiously “that public provision may be potentially more efficient than private, in certain settings.”

The overall impression from previous review studies is mixed. Some studies found that public hospitals are more efficient than private, while others found no significant difference. In general, it appears that PNFP hospitals tend to be closer to public hospitals in outperforming PFP hospitals in terms of quality and efficiency.

These diverging and somewhat surprising results inspired two groups of scholars [ 23 , 46 ]) to investigate the methodological basis for the results. The authors emphasized that case selection, methodological approach, time period and region are important underlying factors. A general observation across the studies was that the true effect of ownership seems to depend on the institutional context and that there are significant differences across regions and markets and over time.

The aim of this paper was to add an update to the results described above. We do that by providing a scoping review of peer-reviewed primary studies on public–private comparisons in specialized health care. We focused on studies that were conducted over the past decade within the European region.

Scoping reviews aim to “map rapidly the key concepts underpinning a research area and the main sources and types of evidence available and can be undertaken as stand-alone projects in their own right [ 2 ]. These reviews can typically have any of four motivations: (1) to “examine the extent, range and nature of research activity,” that is, a mapping to elucidate the extent and range of research in the area; (2) “to determine the value of undertaking a full systematic review”; (3) to “summarize and disseminate research findings”, operating in the direction of a systematic review, describing findings in greater detail and acting to summarize and disseminate findings to key stakeholder audiences with the intention of informing those stakeholders and eliminating or reducing the need to undertake a more in-depth review; and (4) to “identify research gaps in the existing literature.” In our case, we aimed to summarize research findings and generate questions for further studies and systematic reviews.

The review was based on a methodical approach inspired by the British EPPI-Centre’s methodology. This review was broader than review methodologies used within the Cochrane and Campbell collaborations, which emphasized randomized controlled trials (RCTs) as the gold standard [ 38 ]. The present review also included a broader range of methodological designs and quantitative and qualitative studies Petersen et al. [ 42 ].

The literature search was conducted using PubMed, EconLit and Web of Science databases. The search was limited to papers published from 2006 to 2016. The limitation to the most recent decade was to avoid too much overlap with previous reviews while including the most recent studies. The inclusion criteria were papers written in English that dealt with the European region. The search strategies for the databases are presented in Table  1 .

The assessment and compilation of the final sample of relevant studies included three phases. Phase 1 included a search for relevant literature. The initial searches resulted in 480 studies: 354 from PubMed, 93 from EconLit and 53 from Web of Science of which some were duplicates. In phase 2, the abstracts were sorted using the categories not relevant, perhaps relevant and relevant. The not relevant category included papers that were not based in Europe or in which public–private comparisons were not found. The perhaps relevant category included papers whose suitability could not be judged solely on the abstract. Phase 3 included the final assessment of the relevance of the papers. For the relevant or perhaps relevant abstracts, the full papers were further examined, which resulted in grouping the studies that were finally included in the study and studies that were found not relevant after the full paper was read. In this phase, the not relevant papers were mostly theoretical papers, papers in which there were, eventually, no empirical public–private comparisons or very vague descriptions of the comparative material. At this stage of the process, we also excluded studies that addressed outsourcing, privatization and corporatization of hospitals with a focus on the dynamic process of transfer from one ownership type to another.

The final sample of studies that fulfilled the inclusion criteria was 24 papers. All of the papers were published in peer-reviewed journals, and we did not conduct further quality evaluations as the papers had undergone a peer-review process (Fig.  1 ).

Overview of the review procedure

The studies represented 10 countries (Table  2 ). Since 2006, we observed a slight increase in the number of papers published on the subject (Fig.  2 ). This increase confirms the trend observed by Hollingsworth although he reported a “dramatic” increase over the past decades [ 33 ].

Number of studies by year

Most often, the studies in this sample involved comparisons of two groups: public and private hospitals ( n  = 13). However, the definitions of public and private varied. Eleven studies made clear distinctions between public, PFP and PNFP hospitals. Economic effects were explored in 17 studies and quality in seven studies (in three studies, it was used as a control for economic effects). Patient selection was mentioned in 15 studies but discussed explicitly in only seven studies.

The majority of the studies ( n  = 17) found in the database searches addressed the economic performance of public and private specialized care organizations. Seven studies addressed quality.

In terms of economic performance, 15 studies compared public (PUB) hospitals to PFP hospitals. Some studies reported technical, cost and profit efficiency (see Table 3 ). About half of these studies reported that public hospitals are superior to PFP hospitals in terms of efficiency. Most of the other studies found insignificant differences. Only one study reported that PFP hospitals have better profit efficiency. Eight studies compared the performance of PFP and PNFP hospitals. The majority of these studies found that PNFP hospitals are superior in terms of technical, cost and profit efficiency. Only one study pointed to responsiveness as a performance measure where PFP hospitals are better than PNFP hospitals. Finally, we found 11 studies compared PUB and PNFP hospitals. Most of these studies reported insignificant differences. In the remaining studies, we found slightly more studies presented PUB hospitals as superior to PNFP hospitals.

Overall, it seems that in terms of economic performance the public hospitals in the 17 studies representing more than 5500 hospitals across Europe perform better than PNFP hospitals, which, in turn, perform better than PFP hospitals. However, a sizeable number of studies did not find significant differences. In terms of quality, the results were mixed, and it is not possible to draw clear conclusions about the superiority of an ownership type.

The following sections provide details about the studies and their results.

Economic performance: Technical, cost and profit efficiency

Berry et al. [ 11 ] looked at operating room productivity in independent anesthesiology departments within German hospitals by using survey data from 87 hospitals. The authors hypothesized that operating room productivity is higher for hospitals run by private corporations compared to those run by the public sector. In the analysis, they found some confirmation of this idea but presented no significant results. The overall conclusion was that hospital size is the single largest predictor of productivity. However, the authors also suggested that micro-level management processes matter.

Kontodimopoulos et al. [ 39 ] found that after controlling for contextual characteristics technical efficiency was not significantly different between public and private dialysis facilities in Greece. The authors concluded that the context rather than ownership influences the performance of service providers. Barbetta et al. [ 6 ] stressed the importance of contextual factors and reimbursement practices in a study in which they looked at the technical efficiency of public and PNFP hospitals in Italy. The authors suggested that the differences in economic performance are related to institutional settings in which providers operate rather than to the ownership per se.

Czypionka et al. [ 19 ] looked at the impact of ownership on efficiency in Austria. Contrary to several previous studies, the authors found that there is a significant association between efficiency and ownership when comparing public and PNFP hospitals. The latter outperform public hospitals in technical efficiency due to different financial incentives.

Herr [ 30 ] found that in Germany PFP and PNFP hospitals are, on average, less cost-efficient and less technically efficient than publicly owned hospitals. This result can be partly explained by the importance of length of stay, which was, at the time, highest in PFP hospitals. Similar results were found in the study by Tiemann and Schreyögg [ 51 ] who evaluated the efficiency of public, PFP and PNFP hospitals in Germany. The results showed that public hospitals perform significantly better than PFP and PNFP hospitals. However, Herr et al. [ 31 ] found no significant differences in cost and profit efficiency between public and PFP hospitals in Germany.

Daidone and D’Amico [ 20 ] looked at how the production structure and level of specialization of a hospital affect its technical efficiency in Italy. They found that PFP hospitals use resources less efficiently compared to public and PNFP hospitals. PFP hospitals work in slightly over-staffed conditions for medical staff while public and especially PNFP hospitals are over-staffed by technical and administrative staff. Caballer-Tarazona et al. [ 17 ] compared public hospitals and public–private partnership (PPP) model hospitals in the Valencia region, but they were not able to determine the effect of ownership on efficiency due to the small sample size.

Comparisons of costs and other economic outcomes

Two studies—both from Switzerland employing similar data—found that hospital ownership does not affect hospital costs [ 24 , 25 ]. Bonastre et al. [ 14 ] analyzed the use of expensive anticancer drugs in public and private hospitals. The authors found that there were significant differences in terms of capacity, volume of activity and case mix between private and public hospitals, but after adjusting for the case mix, there were no differences in the use of expensive drugs between private and public hospitals.

Kondilis et al. [ 37 ] compared the operation and performance of PFP and public hospitals in Greece, focusing on differences in nurse staffing rates, average lengths of stay and Social Health Insurance (SHI) payments (including per diem fees, plus additional fee-for-service payments for services provided during hospitalization) for hospital care per patient discharged. The authors found that there were differences between PFP and public providers operating within the mixed healthcare system. PFP hospitals had lower bed capacity, lower occupancy rates and lower nurse (total and high qualified) staffing rates compared to public hospitals. PFP hospitals are also associated with higher unweighted length of stay and higher payments per discharge, at least in the case of discharged patients are beneficiaries of the SHI funds.

Siciliani et al. [ 45 ], in turn, studied patients’ length of stay in public hospitals, specialized public treatment centers and private treatment centers that provide elective hip replacement in England. The authors found that public and private specialized treatment centers, on average, had 18% and 40% shorter lengths of stay, respectively, compared with public hospitals. The result remained the same after controlling for age, gender, diagnosis and market characteristics. They did not find that patient selection explains differences in the length of stay in different hospital settings.

Augurzky et al. [ 4 ] studied the differences between public, PFP and PNFP ownership types in German hospitals based on their probability of default (PD). According to the results, public hospitals tend to exhibit a PD that is significantly above average. This association indicates that public ownership may conflict with financial sustainability. The authors explained it by stating that it is possible that public guarantees are the key driver to explain the differences. Public backing opens the window that ceteris paribus public hospitals may have higher PDs without being necessarily closer to insolvency than private hospitals.

Schwierz [ 49 ] studied ownership-specific differences in the responsiveness of changes in demand for hospital services in Germany from 1996 to 2006. He found that in the speed of adaptation to increasing demand PFP ownership is superior to public and PNFP ownership. PFP providers also tend to expand in markets with decreasing demand. This result can be partly explained by the results found by Augurzky et al. [ 4 ] for higher probability of default. That is, the defaults of public hospitals nurture the process of privatization of public sector actors in a situation in which the public sector needs to reform their facilities and work practices while at the same time containing costs.

Solborg Bjerrum et al. [ 47 , 48 ] conducted two studies in Denmark that addressed the quality of elective surgeries in public and private hospitals. The 2015 study concerned patients who had cataract surgery in either public or private eye clinics or hospitals from 2002 to 2010. The results showed that patients who have cataract surgery in public hospitals have an overall statistically significant 62% higher mortality rate compared to patients who have cataract surgery in private hospitals or clinics. The potential explanation may be in the patient selection since the results indicate that patients who have cataract surgery in public hospitals are less healthy than patients who have cataract surgery in private hospitals or clinics (see more in the next section).

Another study by Solborg Bjerrum et al. [ 48 ] in Denmark addressed the risk of postoperative endophthalmitis (PE) in public and private eye clinics or hospitals from 2004 to 2012. The results showed that PE risk is 0.36 per 1000 operations in public hospitals and 0.73 per 1000 operations in private hospitals. Further analysis of the clinics revealed that there is homogeneity in the PE risk among the eye departments in public hospitals ( p  = 0.6) but heterogeneity in the PE risk among the private hospitals or eye clinics ( p  = 0.0001). Six private hospitals or clinics (out of 28) had a statistically significantly higher PE risk compared with the eye departments in public hospitals.

The third study from Denmark concerned how ownership affects professional behavior, treatment quality and patient satisfaction. In a mixed-methods study, Bøgh Andersen and Jakobsen [ 16 ] found that private clinics optimize non-clinical factors, such as wait times, more than public providers. The clinical procedures in the clinics, however, were very similar, and private clinics did not achieve better clinical results. Patient satisfaction was still higher in private clinics. Thus, the general conclusion of the study was that although ownership seems to influence certain aspects of care, the high level of professionalization neutralizes the effect which can be seen in the clinical results.

Pérotin et al. [ 41 ] studied whether hospital ownership affects the level of quality reported by patients in areas other than clinical quality (information and interpersonal care, respect for privacy, dignity and hospitality and delays) in England. The authors found that results vary across specialties and patient groups. The sum of all ownership effects was not statistically significant which led the authors to conclude that hospital ownership does not seem to determine the level of quality of the average patient’s reported experience. The authors also stated that the differences in the quality levels between the private and public sectors are mostly attributable to patient characteristics, patient selection into public or private hospitals and unobserved and specific hospital characteristics, rather than to hospital ownership.

Sanjay et al. [ 44 ] studied patient selection criteria, anesthetic preferences and outcomes of elective inguinal hernia repair in public and private sectors in England. The authors found that the mean wait time for patients undergoing hernia repair is 129 days in the public sector (range 16–379 days) and 15 days (range 8–61 days; p  = 0.001) in the private sector. Caballer-Tarazona et al. [ 17 ] found some evidence that private ownership (PPP) seems to have a positive effect on some quality dimensions, such as access to care. In readmissions, Berta et al. [ 12 ] found that PNFP hospitals show the highest frequency of readmissions compared to public and PFP hospitals.

Sanjay et al.’s [ 44 ] results also showed differences in treatment practices: Anesthesia appears to be the preferred option in the private sector (52%) and local anesthesia in the public sector (66%; ( p  = 0.0002). After a follow-up at 6 months, there was a postal questionnaire survey regarding chronic groin pain and satisfaction rates. No statistically significant difference was noted in the incidence of post-operative complications, recurrence and groin pain and satisfaction rate between the patients treated in public or private facilities. Grilli et al. [ 27 ], in turn, found that ownership status and payment structure have a strong impact on the adoption and use of a new technology, drug-eluting stents. Public hospitals use drug-eluting stents more selectively than private hospitals targeting the new device at patients who have a high risk for adverse effects.

Grotle et al. [ 28 ] studied sociodemographic, lifestyle and clinical characteristics in patients who were operated for lumbar disc herniation in public and private clinics in Norway. The authors evaluated whether selection for surgery and surgical treatment differed between public and private clinics. The main results were that more patients operated in private clinics are sent home the same day of surgery, and a larger proportion of the patients receive prophylactic antibiotic treatment. There were also more complications in public clients compared to the private clinics. However, the patients treated in the private sector were different compared to the patients treated in the public clinics. This, again, may be the explanation behind the results. We turn to the discussion on patient selection in the following section.

Operational differences

Patient selection.

In terms of performance, it is relevant to assess whether hospitals engage in patient selection to reduce their risks and costs. In an unregulated competitive market, this may be a rational reaction, but it also creates a problematic bias in the results if the patient base varies significantly between public and private hospitals in individual studies.

Solborg Bjerrum et al. [ 47 ] found that patients treated in public and private settings are significantly different. The mean age at first eye cataract surgery decreased statistically significantly during the study period but significantly more so in patients operated in private hospitals or clinics than patients operated in public hospitals. Furthermore, the results of the mortality analyses indicated that patients who have cataract surgery in public hospitals are not as healthy as patients who have cataract surgery in private hospitals or clinics. Bøgh Andersen and Jakobsen [ 16 ] found that private hip replacement clinics have fewer complications than patients than public clinics.

Berta et al. [ 12 ] showed that private hospitals are involved in cream skimming at a much higher rate than public and not-for-profit hospitals. Sanjay et al. [ 44 ], in turn, found in England that patients undergoing surgery in the private sector are slightly younger compared to those treated in the public sector, that the number of patients with the American Society of Anesthesiologists (ASA) grading system grades III and IV is higher in the public sector (28.6%), and that there are a higher number of ASA I and II (83%) patients in the private sector.

In a study conducted in Italy, Grilli et al. [ 27 ] showed that patients in public hospitals are older and more likely to undergo percutaneous coronary intervention (PCI) for indications such as acute myocardial infraction and unstable angina than patients in private hospitals. In addition, patients with stable angina are more prevalent in private hospitals than in public hospitals. Furthermore, patients with multivessel disease who undergo PCI with stenting are significantly more prevalent in public centers with and without open-heart surgical facilities than in private centers. Finally, the proportion of patients with high-risk lesions is higher in public hospitals than in private hospitals.

Grotle et al. [ 28 ] found that patients who have lumbar disc herniation surgery in a private clinic are somewhat younger (1.3 years), are more likely to be male, have higher education and are less likely to be unemployed. The proportion of patients who were on sick leave was somewhat higher in private clinics than in the public sector. However, the duration of sick leave before surgery was significantly higher. In the public sector, the mean duration was 24 weeks (SD = 36.4) whereas in the private sector it was around 15 weeks (SD = 20.7). Grotle and colleagues also found that the proportions of disability and retired pensioners are more than double in the public sector compared to that for private clinics. There were also higher proportions of patients who smoked and were obese (BMI > 30) in the public health services. Furthermore, public sector patients used more pain relief, had a longer duration of pain in the back and leg, and had more comorbidities, such as heart disease, hip osteoarthritis, depression and chronic lung diseases. There was also a higher ASA grade among patients operated in public hospitals.

In sum, the limited number of studies analyzing patient selection indicated that public hospitals tend to treat patients who are older and have lower socioeconomic status, riskier lifestyles and higher levels of co-morbidity and complications than patients treated in private hospitals.

Other operational dimensions

Other operational dimensions, such as differences in staff composition, skill level and working conditions, are very likely, but were not reported systematically in the studies included in this study sample. Berta et al. [ 12 ] analyzed effects of distortions (i.e., upcoding, cream skimming and readmissions) induced by the prospective payment system on hospitals’ technical efficiency in Italy. They found that PNFP and public hospitals have the same efficiency levels, while PFP hospitals have the lowest technical efficiency. This could be at least partially explained by the finding that private hospitals are more engaged with cream skimming which, in turn, was found to have a negative impact on hospitals’ technical efficiency. The role of the payment structure was also taken up by Augurzky et al. [ 4 ]. They found that public hospitals tend to exhibit PD at much higher levels than the hospitals in the sample did, on average. This could be explained by the public backing which affects hospital incentives to perform in a financially sustainable way (compare, e.g., [ 40 ]). Differences in financial incentives to hospitals of different ownership status were also brought up by Czypionka et al. [ 19 ] and Barbetta et al. [ 6 ], and both suggested that the different financial incentives are actually the key driver behind the different results in performance.

The study by Bøgh Andersen and Jakobsen [ 16 ] suggested that non-clinical practices, such as wait times, differ between public and private sectors, but in terms of clinical practices, organizations operate similarly. Kondilis et al. [ 37 ] found that PFP hospitals have lower bed capacity, lower occupancy rates and lower nurse staffing rates compared to public hospitals. Staffing rates were also discussed by Daidone and D’Amico [ 20 ] who found that PFP hospitals work in slightly over-staffed conditions for medical staff while public and especially PNFP hospitals are over-staffed by technical and administrative staff.

Numerous important theoretical contributions suggest that private hospitals should outperform public hospitals in terms of efficiency [ 19 , 31 , 52 ]. However, as we have seen, the empirical evidence from the regulated and mixed healthcare markets in Europe is much more diverse. Although many studies reported insignificant results, the majority of the remaining studies found that public hospitals perform better than PNFP providers, which, in turn, show slightly better performance than PFP hospitals in terms of efficiency measures (see Table 3 ). This result is in line with the conclusion in previous review studies, such as Hollingsworth [ 33 ] who summarized his findings as follows: “Cautious conclusions are that public provision may be potentially more efficient than private, in certain settings.” Tiemann et al. [ 50 ] concluded that in line with the evidence found in studies from other countries, especially the US, the evidence from Germany suggested that private ownership (i.e., PNFP and PFP) is not necessarily associated with higher efficiency compared to public ownership.

The last part of the Hollingsworth quote is important as it points to the discussion we launched in the introduction of this paper. Namely, that the context is important for understanding the results. Several studies discussed the specifics of the financing system, the contracting process and the degree of competition or monopoly in the market as important factors in determining the effects of ownership. In general terms, it appears likely that results are sensitive to specific circumstances and regulatory setup. Or as stated in one of the previous review studies,” [t]he true effect of ownership appears to depend on institutional context, including differences across regions, markets, and over time” [ 23 ].

Drawing on the theoretical contributions from the introduction, we speculate that variation in the results across countries and over time may be partially explained by differences in transaction costs, market structure and market maturity. High transaction costs may affect efficiency results for private providers more than for public providers, as administrative burdens may be internalized by public organizations. Market structure is a key issue as monopolies are likely to lead to lower efficiency, whether public or private. This means that diverging results across studies may be explained by underlying variations in market structure. Market maturity may also influence results across studies. As explained in the introduction, cost reductions tend to be highest in the first rounds of competitive bidding, while private and public agents adjust over time. Unfortunately, the studies did not report systematically on transaction costs, market structure or market maturity.

In terms of the ownership argument presented in the introduction, several countries operate with different types of private ownership, and PNFP organizations tend to do well in comparison with their PFP counterparts. The main explanations suggested in the studies point to the difference in profit orientation and the motivation of employees as key factors for explaining this. However, more research should be devoted to explaining these observations, based on the differences in the structure, operational practices and historical role of not-for-profits in specific institutional contexts.

Another theoretical point (usually not addressed clearly) in comparative public–private provider studies is that the political reasons for using private actors can vary significantly and that this is likely to have impact on the results. Contracting out can be done for purely ideological purposes. It may be done to save costs, to increase the service and quality or to boost a market and promote the development of private enterprise. This means that the use of private actors can be successful from some perspectives but not from others.

An important observation from the present review is that many studies that addressed the economic effects of ownership failed to account for quality and operational differences, such as patient selection, although this is potentially very important for the economic results. This represents an important barrier for cross-study comparison, as the tendencies regarding economic performance may be associated with different outcomes in different studies and contexts. An underlying reason for this observation is the challenge of measuring quality consistently. The literature distinguishes among input, process and outcome quality. Many studies focused on the two first dimensions as proxies for the overall quality, as it is easier to obtain data on these issues. However, the real test of benefits to patients lies in the outcome quality. There are extensive efforts to improve the collection of such data in many countries, but this effort has not yet been sufficiently integrated in efficiency studies.

In addition to the theoretically based explanations, there may be specific methodological explanations for the diverse results. Shen et al. [ 46 ] investigated such issues (also [ 23 ]. They found that variation in the direction and size of ownership effects can be explained by differences in research focus and methodology as described above.

Another methodological issue is that the number of studies and underlying cases included in this scoping review may be insufficient to show clear patterns. This argument is somewhat contradicted by the fact that this study can be seen as an extension of previous review studies, which also tended to show mixed results with a slight tendency to favor public and PNFP organizations as shown above.

Overall, it seems fair to conclude that contextual circumstances can be at least as important as ownership. Furthermore, that we need more systematic analysis of the dimensions of the context in order to find patterns in the relationship between contextual circumstances and performance for public and private providers.

This paper investigated whether there is evidence that private delivery organizations perform better than public delivery organizations in European healthcare systems. This topic was studied using a scoping review of the available evidence from recent studies conducted within the European region. We identified 24 studies that reported economic efficiency measures or quality in their comparison of hospital organizations with different ownership forms. The studies covered a wide range or European countries, including Austria, Germany, England, France, Greece, Italy, Spain, Switzerland and Norway. The majority of the studies ( n  = 17) found in the database searches addressed the economic performance of public and private specialized care organizations. Seven studies addressed quality.

In terms of economic performance, most studies focused on technical efficiency using DEA or SFA techniques. Fifteen studies compared PUB hospitals to PFP hospitals. Some studies reported technical, cost and profit efficiency (see Table 3 ). About half of these studies reported that public hospitals are superior to PFP hospitals in efficiency. Most of the other studies found insignificant differences. Only one study reported that PFP hospitals have better profit efficiency. Eight studies compared the performance of PFP hospitals and PNFP hospitals. The majority of these studies found that PNFP hospitals are superior in terms of technical, cost and profit efficiency. Only one study pointed to responsiveness as a performance measure where PFP hospitals are better than PNFP hospitals. Finally, we found 11 studies compared PUB hospitals and PNFP hospitals. Most of these studies reported insignificant differences. In the remaining studies, we found slightly more studies presented PUB hospitals as superior to PNFP hospitals.

Summing up, our review of 17 studies representing more than 5500 hospitals across Europe showed that public hospitals are most frequently reported as having the best economic performance compared to PNFP and PFP hospitals. PNFP hospitals are second, while PFP hospitals are least frequently reported as superior. However, a sizeable number of studies did not find significant differences. In terms of quality, the results were mixed, and it is not possible to draw clear conclusions about the superiority of an ownership type. A few studies analyzed patient selection. They indicated that public hospitals tend to treat patients who are slightly older and have lower socioeconomic status, riskier lifestyles and higher levels of co-morbidity and complications than patients in private hospitals.

This scoping review pointed out shortcomings in the available studies, and future studies are needed to investigate the relationship between contextual circumstances and performance. A significant weakness in many studies was the failure to account for quality, patient selection and other operational dimensions, which may have influenced the results. This weakness should also be addressed in future comparative studies.

Abbreviations

Average length of stay

The American Society of Anesthesiologists

Body mass index

Corrected ordinary least squares

Data envelopment analysis

Diagnosis related group

Percutaneous coronary intervention

Probability of default

Private for-profit

Private not-for-profit

Public–private partnership

Randomized controlled trial

Standard deviation

Stochastic frontiers analysis

Social Health Insurance

Specialist treatment center

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Acknowledgements

We would like to acknowledge the research group of the project Privatizing the health care sector: Expansion of voluntary, private health insurance and private for-profit hospitals in the Nordic countries funded by the Norwegian Research Council (Grant No. 238133).

The study was funded by the Norwegian Research Council (Grant No. 238133, Privatizing the health care sector: Expansion of voluntary, private health insurance and private for-profit hospitals in the Nordic countries). The funding body was not involved in the study.

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Tynkkynen, LK., Vrangbæk, K. Comparing public and private providers: a scoping review of hospital services in Europe. BMC Health Serv Res 18 , 141 (2018). https://doi.org/10.1186/s12913-018-2953-9

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Hospitals' contributions to their communities: Should they be regulated?

Cory e. cronin.

1 Department of Social and Public Health, College of Health Sciences and Professions and Appalachian Institute to Advance Health Equity Science, Ohio University, Athens, OH, United States

Simone R. Singh

2 Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, United States

Jason S. Turner

3 Department of Health Services Management, Rush University, Chicago, IL, United States

Connie J. Evashwick

4 Milken Institute School of Public Health, George Washington University, Washington, DC, United States

Introduction

Hospitals are often epicenters of their communities. In addition to the role they play in providing clinical care for the ill and supporting population health efforts, many hospitals have a mission that includes caring for all members of the community, especially those in need. Recent efforts have been made by governments to set expectations for how hospitals contribute to their community beyond the provision of patient care. This has been codified into law in the United States of America (USA) over the past two decades ( 1 ), but considered and discussed in other countries as well ( 2 , 3 ). We raise the question here: To what extent is it necessary or even beneficial to regulate hospital-community relationships through public policy?

We propose the following inquiries.

• First, does a hospital contribute to its community, beyond the acute care services it offers, naturally and organically, or must the role of the hospital in the community be mandated by legislation and regulation?
• Second, if regulated, what constitutes a “contribution” to the community's health and wellbeing, and can that contribution be measured?
• Third, can the impact of the hospital's activities on the community's health status be measured? If so, what metrics should be used, and what is the target, standard, or threshold hospitals must reach to fulfill their community benefit obligations?

We consider each of these questions briefly, recognizing that more extensive analyses are warranted.

Hospitals' contributions to their communities

Hospitals now and throughout history have been social institutions and have offered myriad services to their constituents. Numerous examples exist, from Hotel Dieu in Paris to the almshouses of medieval Europe and the nascent USA, to the early seamen's hospitals that isolated sailors with contagious diseases to prevent the spread of infections in the community ( 4 – 7 ). Hospitals throughout the world founded by religious institutions have served as providers of health care but also as schools and community centers. Today, the size and stability of many hospital organizations mean that their economic contributions as employers and purchasers of local services are so substantial that they are often considered to be critical anchor institutions responsible for improving the social determinants of health and community wellbeing through targeted hiring practices, selection of local vendors, career laddering, real estate development, and financial investment ( 8 – 10 ). Community outreach and engagement are prevalent in many forms, from organizing health fairs to allowing community support groups to use hospital space for meetings. Leaders of hospitals often report such activity as integral to their organizational identity and culture ( 11 – 13 ). The International Hospital Federation, soon to celebrate its 100th anniversary, documents how hospitals throughout the world have contributed to their communities in myriad ways. As an example, the newly formed Geneva Sustainability Centre ( 14 ) showcases current innovations by hospitals across the globe to protect the climate and environment.

Regulation of community benefit in the USA

In the USA, government efforts to establish community expectations for hospitals have attempted to formalize hospitals' philanthropic foundations in order to capture tax revenues and, more recently, to address gaps in the healthcare delivery system. This effort initially dates back to a 1969 tax ruling, when the federal government first articulated expectations of “charity care” in exchange for exemption from federal income tax ( 15 ). About half of the 50 states comprising the USA have also enacted some form of regulation attaching exemption from state income tax to the provision of uncompensated care for those unable to afford care ( 16 ). The rationale is that not-for-profit hospitals are providing resources directly to the community in lieu of paying taxes. In 2022, 58% of community hospitals, or 2,960 in total, had not-for-profit status ( 17 ).

The USA federal tax authority, the Internal Revenue Service (IRS), requires that every organization that seeks to qualify for tax exemption must report annually on its activities and financial transactions. Not-for-profit hospitals' reporting of specific activities assumed to benefit the community began in 2009. Table 1 provides an abbreviated list of the types of activities USA hospitals report to the IRS and examples of what is reported.

Hospital community benefit activities.

The IRS regulations require extremely detailed and complex reporting, applying data from multiple departments in the hospital. There are now more than a dozen years of data to assess the impact of the community benefit policy. Although reporting has been somewhat codified by the information systems available, no metrics have been specified for each of the activities. For example, for health fairs, is reporting the number of people who come by a booth acceptable? Are denominators as well as numerators required? Each hospital defines its own “community” and can determine its own system of accounting for community benefit activities.

For most hospitals, the expectations are vague, both in regard to the efforts to be made and the extent of resources to be dedicated. In 2020, the General Accounting Office (GAO), a federal government agency, issued a report noting a lack of a “well-documented process” for the review of hospitals' community benefit activities ( 18 ). Six recommendations were offered to improve the community benefit reporting and monitoring processes. Whether or not these are being implemented is not evident as of 2022.

Many of the activities that count as community benefits are difficult to document, difficult to quantify, and difficult to assess. The most easily measurable aspect, and the one still most prominent in spite of conceptual shifts, is the cost of medical care provided at no or reduced cost to individual patients. The vast majority of USA hospitals' community benefit spending is focused on providing care to individual patients rather than dedicated to improving community health outcomes. Studies over the past ten or more years have consistently indicated that 85–90% of community benefit dollars reported by not-for-profit hospitals were attributed to uncompensated care ( 18 – 20 ). This proportion has prevailed despite the major financial changes brought about by the 2010 Affordable Care and Patient Protection Act (ACA) law, federal initiatives to promote value-based payment, the pandemic, or any other systemic change.

A final consideration is the cost to not-for-profit hospitals of conducting and reporting on community benefit activities. The costs of operating a department in a hospital that carries out community benefit activities or conducts the required 3-year community health needs assessment can be claimed as “community benefit.” These costs aren't thoroughly reported, and no national data exist. If one assumes that each of the 2,960 hospitals spends at least $100,000 annually, the annual cost to comply with the federal regulation is nearly $3 billion. Could this money be spent on community health in better ways?

How much is “enough”?

Not-for-profit hospitals in the USA spent more than $100 billion on community benefit in 2017, according to pre-pandemic reporting ( 21 ). Although some states have specified a percent of gross or net patient revenues as a required minimum for state income tax exemption for hospitals, no financial target has been declared at the federal level. The federal government has no answer to the question asked by the hospital industry, “How much is enough?”

At the same time, proprietary (for-profit) hospitals in the USA have been compared to not-for-profit hospitals with regard to their contributions to the community. A number of studies have found little difference in types of activities or estimated dollar amounts ( 12 , 13 , 22 ). Government and select specialty hospitals are exempt from the community benefit requirement. If the assumption is that the hospital is a social institution with an obligation or mission to serve its community, why should the government excuse its own institutions from making similar contributions?

What happens when a not-for-profit hospital experiences a deficit? Is it expected to withdraw from the community, or to continue with community outreach at the expense of acute inpatient care? The law in the USA is silent.

A major flaw of the community benefit policy is that no logic model delineates how any of the activities that “count” toward community benefit relates to the overall health of the community. Despite the array of data sets that characterize the health behaviors or health status of a community, no single measure of a “healthy community” has been determined. Moreover, the methods for measuring impact of any single intervention on a community characteristic are not fully refined. We can say that less smoking is better than more smoking for one's health, and some techniques are effective at reducing smoking in some populations, but we can't precisely measure the impact on the health of the community of a community-wide stop-smoking campaign organized by a hospital but supported by many institutions throughout the community. The question of attribution is neither raised nor addressed in the reporting methodology. A recent collection of research articles pertaining to community benefit provided scarce evidence that the policy at the federal or state level has a direct and measurable change on the health status of a community ( 23 ). Are hospitals the most appropriate mechanism to fill gaps left by deficiencies in the health system?

Discussion and conclusions

Of the three questions posed initially, we conclude: (1) Hospitals of all types throughout the world contribute to their communities in myriad ways without laws that require them to do so. Mission is often a stronger driver than regulations. (2) The many ways in which a hospital contributes to the health of its community elude measurement of the magnitude of an activity, the effect on health status (which is itself a vague term to measure), or the ability to attribute change directly and exclusively to the hospital's actions. (3) No clarity exists on “how much” a hospital should do for its community, either as a moral or regulatory obligation, or to achieve a change in the community's health status.

Although hospitals are able to play an important role in filling a gap of access and coverage for some individuals, forcing a hospital to engage in random activities with unclear amounts of resources is not a sufficient policy approach to improve health and wellbeing of a community or population. Community benefit laws and regulations, such as the ones currently on the books in the USA, might encourage community engagement. However, the lack of clear guidelines, arbitrary measures of process and outcomes, and no definitive targets to assess hospitals' contributions to community health result in these laws and regulations being costly but not necessarily effective. Are we asking hospitals/health systems to do more than they were designed to do? A thoughtful and thorough policy analysis of the community benefit policy in effect in the USA, potentially comparing states that do and do not require specific dollar amounts of attributed activities, would contribute to assessing the strengths and weaknesses of the current community benefit regulations.

To promote hospitals' contributions to their communities, we recommend that governmental policies of the future seek evidence-based, effective, measurable ways to involve organizations in improving the health of communities, allowing hospitals first and foremost to care for patients, and rewarding rather than penalizing engagement in activities aimed at improving the health of their communities more broadly.

Author contributions

CC, CE, SS, and JT contributed to the conceptualization, writing, and editing of this manuscript. All authors contributed to the article and approved the submitted version.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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It doesn’t even register as something gross.” “Look, I walk into the room. I say, hey, sounds like you have Covid. And I might order a chest X-ray. I might order blood work. I might order catheters. All that stuff is done by the nurse. I may have spent 10 minutes. The nurse might spend seven or eight hours actually in the room, caring for them. Let’s say there was a day that nurses didn’t come to the hospital. It’s like, why are you even opening?” “Ibuprofen.” 12-hour-plus shifts, isolated in this windowless room, these nurses survive by taking care of each other. “Aww, thank you.” And by finding small doses of levity. [MUSIC - JAMES BAY, “LET IT GO”] “(SINGING) Wrong. Breeze.” “I’m getting older now, and there’s all these new young nurses coming out. And I feel like a mom to all of them. Morgan, she’s got big aspirations. She loves to snowboard, and she’s so smart. And Deb, Deb’s just— she’s funny.” “I tease her all the time. I can tell her to do anything, and she’ll just do it because I think she’s scared of me because I just always say, make sure you have no wrinkles in those sheets.” The patients spend most of their time on their stomachs because it makes it easier to breathe. But the nurses have to turn them often to prevent pressure sores. There was one woman in her 50s who was so critical that this simple procedure risked killing her. “Even just turning them on their side, their blood pressure will drop. Their oxygen levels will drop.” “Her heart had actually stopped the day before. And so the concern was if it was going to make her heart stop again.” “Then come over. Push.” “We were all watching the monitors.” “I felt relieved like, whew, we did it.” Arizona’s a notoriously anti-mask state. And it faced a huge post-holiday surge in Covid cases. In January, the month I was there, Arizona had the highest rate of Covid in the world. As a result, I.C.U.s like this one have too many patients and not enough nurses. “Because they’re so critical, they need continuous monitoring, sometimes just one nurse to one patient with normally what we have is two patients to one nurse. But there definitely are times when we’re super stretched and have to have a three-to-one assignment.” A nurse shortage has plagued hospitals over the past year. To help, traveler nurses have had to fly into hotspots. Others have been forced out of retirement. Especially strained are poorer hospitals like Valleywise, which serves a low-income, predominantly Latino community. “Many of our patients are uninsured. Some of them have Medicaid, which pays something but unfortunately not enough.” This means they simply can’t compete with wealthier hospitals for nurses. “There is a bidding war. The average nurse here, give or take, makes about $35 an hour. Other hospitals, a short mile or two away, might pay them $100.” “We lost a lot of staff because they took the travel contracts. How can you blame them? It’s sometimes a once-in-a-lifetime opportunity to make a lot of money.” “Every single day I’m off, I get a call or a text. ‘Hey, we desperately need help. We need nurses. Can you come in?’” This nursing shortage isn’t just about numbers. “Physically it’s exhausting. We’re just running. We don’t have time to eat or drink or use the restroom.” “They have kids at home, doing online school. And I think, gosh, they haven’t even been able to check on their kids to see how they’re doing.” “My days off, I spend sleeping half the day because you’re exhausted. And eating because we don’t get to eat here often.” Nurses have been proud to be ranked the most trusted profession in America for nearly two decades. But during Covid, many worry they aren’t able to uphold the standards that earned them such respect. “I can’t give the quality of care that I normally would give.” “It’s absolutely dangerous.” “That’s demoralizing because we care. We’re nurses. It’s our DNA.” Ana had been in the hospital for over a month. Her family told me she was born in Mexico. She came to the States 34 years ago, first working in the fields before eventually landing her dream job in education. She’s beloved at her school. Former students often stop her in town and excitedly shout, Miss Anita. She was very cautious about Covid. She demanded her family always wear a mask and yelled at them to stay home. Yet, tragically, she somehow still caught it. “She had been declining over the course of several days. It’s a picture we have seen far too often that we know, this one is going to be coming soon.” Because there is no cure for Covid, the staff can only do so much. Once all the ventilator settings and the medications are maxed out, keeping a patient alive will only do more harm than good. So Ana’s family was forced to make a tough decision. “And I talked to family and let them know that we have offered her, we have given, we have done everything that we can, there’s nothing more that we can do. The family made the decision to move to comfort care.” “If I’m there while someone’s passing, I always hold their hand. I don’t want somebody to die alone. That’s something that brings me peace.” “Thank you.” “Thank you.” “Dance floor is packed. People hugging, holding hands, and almost no one wearing a face mask.” “I think like many health care workers, I’m angry a lot. And my faith in humanity has dwindled.” “How can you think this isn’t a real thing? How can you think that it’s not a big deal?” “Free your face. Free your face.” Arizona Gov. Doug Ducey has advocated for personal responsibility over mask mandates even though he’s been photographed maskless at a gathering and his son posted a video of a crowded dance party. “Even on the outside, they go, I don’t care. I’m not wearing a mask. I’m not getting the vaccine. That’s bullshit. The second they come into the hospital, they want to be saved. Never do they say, ‘I made the decision. I’m accepting this. Don’t do anything, doctor.’” Half a million people in this country have died from Covid. Many have been in I.C.U.s with nurses, not family members holding patients’ hands. “I always wonder, are they still going to be there when I get to work? It’s on my mind when I get home. Are they going to make it through the night? There’s one that I can think of right now.” One patient in his late 50s was so critical that he required constant supervision. Each of his breaths looked painful. “There was one day that he was kind of— he was looking a little bit better. And so he was able to shake his head and smile. And we set up a video call for him. And it was just the sweetest thing ever. I could hear his little grandson— he was probably 4 years old or so. And I saw him on the screen, too. And he was just jumping up and down, so excited. ‘You’re doing it, Grandpa. You’re doing it. We love you. Look at you. You’re getting better.’ It just broke my heart. It broke my heart. He’s one that I don’t think is going to be there when I get back on Sunday.” But I’d already been told something Sara hadn’t. The patient’s family had decided to take him off life support. “Yesterday they did? Oh. And I just think of his little grandson. And ‘you’re doing it, Grandpa. You’re doing it.’” He wasn’t the only patient who didn’t make it. When I went back to the hospital, I noticed that the bed of the patient I’d seen get flipped over was empty. My heart sank. I knew this meant she’d passed away. “What’s sad is when I go back, those beds will be full. They’ll have somebody else there just as sick with another long stretch of a few weeks ahead of them before it’s time for their family to make that decision.” I’d never before seen someone die. And even though I didn’t know these people, witnessing their deaths left me sleepless, exhausted, and depressed. It’s unfathomable to me that these nurses have gone through that every single week, sometimes every single day for an entire year. I assumed the nurses must block out all the deaths to be able to keep going, but they don’t. They grieve every single one. “I’ve always loved being a nurse. It’s what I’ve always wanted to do. And these last couple months, it’s definitely made me question my career choice.” And what makes their situation so tragic is that many of these nurses hide their trauma, leaving them feeling isolated and alone. “We’re the only ones that know what we’re going through. I don’t really want to tell my family about everything because I don’t want them to feel the same emotions that I feel. I don’t want them to know that I carry that burden when it— that it is a lot. I’m Mom. I’m strong. I can do anything. And I don’t want them to see that.” Leadership in the pandemic hasn’t come from elected officials or spiritual guides but from a group that is underpaid, overworked and considered secondary, even in their own workplaces. As so many others have dropped the ball, nurses have worked tirelessly out of the spotlight to save lives, often showing more concern for their patients than for themselves. I worry their trauma will persist long after we re-emerge from hibernation. Covid’s legacy will include a mass PTSD on a scale not felt since World War II. This burden should not be ignored. “Thank you. Thank you. I feel, yeah. And you’re all amazing.” [MUSIC PLAYING]

Nevertheless, we find ourselves too often with a shortage of nursing care. Many decades of research reveal two major reasons: First, poor working conditions, including not enough permanent employer-funded positions for nurses in hospitals, nursing homes and schools. And second, the failure of states to enact policies that establish and enforce safe nurse staffing; enable nurses to practice where they are needed, which is often across state borders; and modernize nurse licensing rules so that nurses can use their full education and expertise.

Training more nurses cannot solve these problems. But more responsible management practices in health care, along with better state policies, could.

Not only are states not requiring safe nurse staffing, but individuals also do not have the information and tools they need to pick hospitals and nursing homes based on nurse staffing or to advocate better staffing at their hospitals and nursing homes.

Ninety percent of the public in a recent Harris Poll agreed that hospitals and nursing homes should be required to meet safe nurse staffing standards. But powerful industry stakeholders — such as hospital and nursing home organizations and, often, medical societies — are strongly opposed and usually defeat legislation.

The New York State Legislature is the first in the postpandemic era to fail to approve proposed safe nurse staffing standards for hospitals. The legislature passed a bill that did not require safe nursing ratios, opting instead for internal committees at hospitals to oversee nursing and patient safety. This happened despite compelling evidence that the legislation would have resulted in more than 4,370 fewer deaths and saved more than $720 million over a two-year study period through shorter hospital stays.

What are the solutions? While there are some actions the federal government could take, the states have most of the power because of their licensing authority over occupations and facilities. The hospital and nursing home industries have long failed to police their members to remove the risk of nurse understaffing. So states should set meaningful safe nurse staffing standards, following the example of California, where hospital nurses cannot care for more than five adult patients at a time outside of intensive care. State policies are tremendously influential in health care delivery and deserve greater public attention and advocacy, as they are also ripe for exploitation by special interests.

In states with restrictive nurse licensing rules, many governors used their emergency powers during Covid surges to waive restrictions. If they were not needed during a national medical emergency, why are they needed at all?

Still, the federal government has a role to play: It should require hospitals to report patient-to-nurse staffing ratios on the Medicare Hospital Compare website, because transparency motivates improvement. The federal government could incentivize the states to pass model nurse practice acts.

We need influential champions taking on special interests so that states will make policy changes that are in the public’s interest. AARP is using its clout to advocate nurse-friendly policies. But health insurers and companies such as CVS, Walgreens and Walmart that provide health care have been on the sidelines.

While we long to go back to pre-Covid life, returning to chronic nurse understaffing in hospitals, nursing homes and schools would be a big mistake. We owe nurses and ourselves better health care resources. The so-called nurse shortage has become an excuse for not doing more to make health care safe, effective and patient-centered. State legislators must do their job. Health care leaders must fund enough positions for nurses and create reasonable working conditions so that nurses will be there to care for us all.

Linda H. Aiken is a professor of nursing and sociology and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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An earlier version of this article misstated the status of legislation on nurse staffing standards in New York State. The bill passed without setting minimum nursing ratios; it did not fail to pass.

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Which perform better: public or private hospitals?

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Over the last few decades, numerous studies have analysed performance differences in the healthcare sector between public and private hospitals across the world.

When delivering healthcare services, can public hospitals outperform private ones? Or is it more likely the other way round?

A major argument in favour of the private sector providing public services is that it could increase service efficiency. But there is mixed evidence that confirms with certainty whether private organisations in the healthcare sector perform better than their counterparts. 

This opens up another question: if private organisations providing public services could lower costs and increase efficiency , what would happen to their public counterparts?   Earlier studies on privatisation tend to give a higher performance ranking to public services provided by privately-owned organisations, but this performance gap has attenuated over the last few years.

Although several studies demonstrate that publicly-owned hospitals in the United States are less efficient than those that are privately-owned, other findings challenge this logic and provide evidence that private hospitals are the ones that tend to be less efficient.   In Europe, several studies show different trends. In Belgium, for instance, publicly-owned hospitals are on average more efficient than their private counterparts. In Germany, some studies show a similar pattern, but others reveal that there are no significant differences in cost efficiency between public and privately-owned hospitals. 

In Asia, public hospitals experience higher costs per patient than those that are owned privately, while in Australia, there are no differences in costs between public and private hospitals.   To clear up these mixed results, we conducted research analysis across healthcare studies for the USA, Germany, Taiwan, Belgium, Spain and Italy using data from public and private hospitals.

In Belgium, publicly-owned hospitals are on average more efficient than their private counterparts

We compared the countries’ differences in both healthcare costs and performance levels . Our aim was to demonstrate whether public organisations in the healthcare sector performed better than private ones or vice versa. Our findings bring good news for public hospitals.

Financial costs and efficiency – who wins?

Some scholars have suggested that because public sector organisations operate without market pressures, they cannot benefit from the information the market provides to improve their performance . Instead, they rely on political will and budgetary changes: both aspects that can limit their production levels.    Regardless of this, our analysis shows a genuine effect in favour of public sector hospitals. We found evidence that the provision of health services is cheaper if provided by the public sector.

Indeed, public sector hospitals outperform their private counterparts when the goal is to reduce financial costs. This is good news for governments and taxpayers: public health services are cheaper and allow for better financial savings.

However, there is a secondary aspect where private hospitals are better: productive performance. The findings show that when technical efficiency is considered, the private sector performs better than its public counterparts.

Public sector hospitals outperform their private counterparts when the goal is to reduce financial costs

Performance differences between countries

When measuring healthcare performance by country, the findings showing that private hospitals tend to be more efficient do not hold for the United States and Germany.    All our estimations for the United States show better performance in public hospitals . Our analysis of German hospitals also finds a similar pattern: public hospitals in Germany tend to be more associated with better performance while private hospitals perform worse.   A possible explanation for these results can be found in the public sector’s performance levels by country published in the World Economic Forum’s Global competitiveness report. According to the report, Germany and the US rank similarly and are identified as having the best performing public sectors worldwide.    On the contrary, Taiwan, and particularly Belgium, Spain and Italy – the four remaining countries in our study – rank much worse in terms of public sector performance.    Our analysis demonstrates that comparing public and private performance requires a broader framework that includes several moderating factors that go beyond whether ownership is public or private. Only by developing further research on these additional factors will we be able to distinguish when and how private organisations could be a better option for delivering health services.

This article is based on joint research by Esade and the Research Institute of Applied Economics published in the International Public Management Journal.

Visiting professor, Department of Strategy and General Management at Esade Business School

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Open Access

Peer-reviewed

Research Article

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

* E-mail: [email protected]

Affiliations Department of Medicine, University of California, San Francisco, California, United States of America, Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California, United States of America, Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom

Affiliation Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America

Affiliation Tri-Institutional MD-PhD Program, Weill Cornell Medical College/Rockefeller University/Sloan-Kettering Institute, New York, New York, United States of America

Affiliation Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America

Affiliations Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom, Department of Sociology, Cambridge University, Cambridge, United Kingdom

• Sanjay Basu, 
• Jason Andrews, 
• Sandeep Kishore, 
• Rajesh Panjabi, 
• David Stuckler

• Published: June 19, 2012
• https://doi.org/10.1371/journal.pmed.1001244
• Reader Comments

Introduction

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

Methods and Findings

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

Conclusions

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

Please see later in the article for the Editors' Summary

Citation: Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D (2012) Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review. PLoS Med 9(6): e1001244. https://doi.org/10.1371/journal.pmed.1001244

Academic Editor: Rachel Jenkins, King's College London, United Kingdom

Received: January 18, 2012; Accepted: May 8, 2012; Published: June 19, 2012

Copyright: © 2012 Basu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: No direct funding was received for this study. The authors were personally salaried by their institutions during the period of writing (though no specific salary was set aside or given for the writing of this paper).

Competing interests: The authors have no competing financial interests. SB, JA, SK and RP are employed at academic medical centers, which receive public sector research finances but also receive revenue through private sector fee-for-service medical transactions and private foundation grants. RP serves on the board of a nonprofit organization (Tiyatien Health) that provides health services in Liberia with approval from and in collaboration with the government and through receipt of private foundation funding, but has received no compensation for this role. SB and JA serve on the board of a nonprofit organization (Nyaya Health) that provides health services in rural Nepal using funds received from both private foundations and the Nepali government; they have also not received compensation for these roles.

Abbreviations: C-section, cesarean section; WHO, World Health Organization

Editors' Summary

Health care can be provided through public and private providers. Public health care is usually provided by the government through national healthcare systems. Private health care can be provided through “for profit” hospitals and self-employed practitioners, and “not for profit” non-government providers, including faith-based organizations.

There is considerable ideological debate around whether low- and middle-income countries should strengthen public versus private healthcare services, but in reality, most low- and middle-income countries use both types of healthcare provision. Recently, as the global economic recession has put major constraints on government budgets—the major funding source for healthcare expenditures in most countries—disputes between the proponents of private and public systems have escalated, further fuelled by the recommendation of International Monetary Fund (an international finance institution) that countries increase the scope of private sector provision in health care as part of loan conditions to reduce government debt. However, critics of the private health sector believe that public healthcare provision is of most benefit to poor people and is the only way to achieve universal and equitable access to health care.

Why Was This Study Done?

Both sides of the public versus private healthcare debate draw on selected case reports to defend their viewpoints, but there is a widely held view that the private health system is more efficient than the public health system. Therefore, in order to inform policy, there is an urgent need for robust evidence to evaluate the quality and effectiveness of the health care provided through both systems. In this study, the authors reviewed all of the evidence in a systematic way to evaluate available data on public and private sector performance.

What Did the Researchers Do and Find?

The researchers used eight databases and a comprehensive key word search to identify and review appropriate published data and studies of private and public sector performance in low- and middle-income countries. They assessed selected studies against the World Health Organization's six essential themes of health systems—accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency—and conducted a narrative review of each theme.

Out of the 102 relevant studies included in their comparative analysis, 59 studies were research studies and 13 involved meta-analysis, with the rest involving case reports or reviews. The researchers found that study findings varied considerably across countries studied (one-third of studies were conducted in Africa and a third in Southeast Asia) and by the methods used.

Financial barriers to care (such as user fees) were reported for both public and private systems. Although studies report that patients in the private sector experience better timeliness and hospitality, studies suggest that providers in the private sector more frequently violate accepted medical standards and have lower reported efficiency.

What Do These Findings Mean?

This systematic review did not support previous views that private sector delivery of health care in low- and middle-income settings is more efficient, accountable, or effective than public sector delivery. Each system has its strengths and weaknesses, but importantly, in both sectors, there were financial barriers to care, and each had poor accountability and transparency. This systematic review highlights a limited and poor-quality evidence base regarding the comparative performance of the two systems.

Additional Information

Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001244 .

• A previous PLoS Medicine study examined the outpatient care provided by the public and private sector in low-income countries
• The WHO website provides more information on healthcare systems
• The World Bank website provides information on health system financing
• Oxfam provides an argument against increased private health care in poor countries

One longstanding and polarized debate in global health concerns the appropriate role and balance of the public and private sector in providing healthcare services to populations in low- and middle-income countries [1] . In recent years, disputes between the proponents of private and public systems have become particularly heated, as the global economic recession that began in 2007 has placed major constraints on government budgets—the major funding source for healthcare expenditures in most countries ( Figure 1 ) [2] . The International Monetary Fund has recommended that countries increase the scope of private sector provision in health care as part of loan conditions [3] , often to reduce government debt [4] . Criticizing such efforts, the international nonprofit organization Oxfam, in its report “Blind Optimism,” concluded that “to achieve universal and equitable access to health care, the public sector must be made to work as the majority provider” [5] . The World Bank responded that it seeks “more pragmatic approaches that build on what is available” by engaging with the private sector in countries where public sector services perform poorly [6] ; the Center for Global Development similarly argued that the Oxfam report “ignored the informal sector,” and that poor people “want to go” to private providers and will “persist in doing so” [7] .

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n  = 190 countries for which data are available. Source: [114] .

https://doi.org/10.1371/journal.pmed.1001244.g001

Generally, this debate has been divided between those seeking universal state-based healthcare availability and those advocating for the private sector to provide care in areas where the public sector has typically failed. Private sector advocates have pointed to evidence that the “private sector is the main provider,” as many impoverished patients prefer to seek care at private clinics [1] . They have suggested that the private sector may be more efficient and responsive to patient needs because of market competition, which they indicate should overcome government inefficiency and corruption [8] . In contrast, public sector advocates have highlighted inequities in access to health care resulting from the inability of the poor to pay for private services. They have noted that private markets often fail to deliver public health goods including preventative services (a “market failure”), and lack coordinated planning with public health systems, required to curb epidemics.

Both sides claim their critics are “ideologically biased” [9] , [10] and selectively draw on case reports to defend their viewpoints [5] , [7] . However, significant conflicts of interest may apply to both groups [11] , as large private international contractors, insurance firms, and non-governmental organizations may benefit from expanding the role of the private sector, while academics who rely on state-funded grant proposals may gain resources from a greater public sector role.

Crucially needed to inform this debate is a systematic review of existing evidence. As Hanson and colleagues note, “A strengthened evidence base on the performance of the public and private health sectors is essential to guide decision-makers towards policy choices that are appropriate for their contexts” [11] . However, in practice, studies comparing the performance of private and public sectors are difficult to implement, for several reasons. First, healthcare services are not universally dichotomized between public and private providers, as some practitioners participate in both state-based and privately owned healthcare delivery systems, and many systems are dually funded or informal. A wide range of arrangements exist for how such expenditures are spent in public versus private clinics, hospitals, and informal settings (see Box 1 for definitions). One example of this complication is the role of informal payments in public facilities. These private–public interactions confound a simplistic comparison between private and public systems. Second, state-based healthcare services and private services have coexisted in many low- and middle-income countries for decades; most countries have a large fraction (but not all) of healthcare expenditures paid for by the state, with most of the remainder paid for by households [12] . In this context, simply defining what is private or public is not straightforward. Private providers are heterogeneous, consisting of formal for-profit entities such as independent hospitals, informal entities that may include unlicensed providers, and nonprofit and non-governmental organizations.

Box 1. Different Public and Private Healthcare Delivery Agents in Low- and Middle-Income Countries

Multinational and national for-profit corporations: for-profit group practices, sometimes associated with hospitals.

Formal individual private providers: individual physicians or other healthcare providers operating in smaller scale healthcare facilities or private pharmacies.

Informal for-profit providers: unlicensed, unregulated providers including shop owners, “injectors,” traditional healers, and birth attendants.

Not-for-profit providers: civil society, non-governmental, and faith-based groups, charities; and community and social enterprises, with varying degrees of regulation and oversight.

Public hospitals, health centers, and clinics: county- and district-level hospitals and clinics, with varying degrees of accessibility and user fees for patients, often having providers that also participate in private sector healthcare delivery.

Public–private partnerships: International or national associations that have varying degrees of for-profit or nonprofit status, or collaborations between for-profit and government/nonprofit entities to deliver services. Also have varying user fees for patients and varying levels of public subsidization for delivering healthcare services.

Although these debates have been highly visible, there is a dearth of reviews on the topic. An initial search of prior systematic reviews and meta-analyses in the PubMed database revealed one recent review, evaluating 80 field-based studies that directly and simultaneously compared service quality in ambulatory public and private care clinics [1] . The analysis found that private outpatient clinics often had better drug supplies and responsiveness than public clinics, but the analysis did not assess other dimensions of health system performance (such as accessibility). The review excluded studies of hospitals, case reports, intervention studies (such as how a sector responded to quality improvement programs), or statistical studies of population-level data.

The aim of the current study is to evaluate available data on public and private sector performance across the key domains of health systems competencies. Our goal is to understand how the private or public nature of a given healthcare delivery institution may impact core healthcare delivery goals. We systematically review published data and studies of private and public sector performance in low- and middle-income countries against six health systems themes used by World Health Organization (WHO), adapted from the 2000 World Health Report [13] . The six themes are as follows: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency [13] ( Table 1 ).

https://doi.org/10.1371/journal.pmed.1001244.t001

Search Strategy

We searched for primary literature in eight major databases using the indexed and free-text terms “private sector,” “privatization,” “public-private sector partnerships,” and “public sector” in various combinations, as described in Text S1 . Because much of the discussion and data collection on this topic has been performed outside of academic circles by international agencies and non-governmental groups, we supplemented the database search by conducting the same keyword searches on the websites of the WHO library database WHOLIS, the World Bank Documents and Reports repository, the United Nations Children's Fund, the United Nations Development Program, the Bill & Melinda Gates Foundation, the Global Fund to Fight AIDS, Tuberculosis and Malaria, Oxfam International, and the Kaiser Family Foundation Global Health Division. The search terms included studies in English, French, Italian, Spanish, Portuguese, or Russian, published from 1 January 1980 through 31 August 2011.

Study Selection

All titles and abstracts found by the search strategy were filtered for relevance to the study objective. Studies must have included data on a population in at least one low- or middle-income country, defined by the 2010 World Bank criteria of having current per-capita gross national income less than or equal to US$12,275 [14] . The full texts of potentially relevant articles were subject to the inclusion criteria listed in Table 2 to ensure they met basic minimum methodological standards. Qualitative studies were included if they specified a systematic methodology for interviews, focus group analysis, historical or political science analysis, or ethnographic observation (see Text S2 for the PRISMA checklist).

https://doi.org/10.1371/journal.pmed.1001244.t002

Data Extraction and Analysis

A data extraction method was designed by three reviewers (S. B., J. A., and D. S.). J. A. extracted the data using a preestablished standard data entry format into a database, with verification by S. B. to ensure consistency of coding. Standard data describing each study were also extracted, including the country where the study was performed, study period, study methodology, number of included participants, primary and secondary outcome measures and end points, and study limitations. Where disclosed, we noted the study funders and agencies. Disagreements between the two reviewers were resolved by consensus among all authors.

The data synthesis was structured into six themes from the updated WHO framework for health system assessment (see Table 1 for themes, subthemes, and indicators used to assess each theme) [13] . Relevant data that did not fall into one of these themes was separately included in the analysis in an “other factors” category that is discussed following the principal results. Reports containing information relevant to more than one theme were included in all related thematic areas. We did not perform further subanalysis of the highest quality studies as the authors could not agree to a vote-counting approach that would apply across the quantitative and qualitative methods and the six WHO themes captured in literature using different types of outcome variables.

The study selection process is shown in Figure 2 as a PRISMA flow diagram. Of the 1,178 potentially relevant unique citations from all literature searches, 102 studies met the inclusion criteria. Key characteristics of the included studies are summarized in Table 3 . Fifty-nine studies were empirical research studies and 13 involved meta-analysis, with the rest involving case reports or reviews. One-third of studies were carried out in the WHO-defined African region ( n  = 32) and another third in the Southeast Asian region ( n  = 34); most were published after 1990. We found that about nine out of ten studies directly compared quality of care in public versus private systems or assessed the demand for or utilization of services; the remaining studies examined drug availability or affordability or compared the cost and efficiency of services.

https://doi.org/10.1371/journal.pmed.1001244.g002

https://doi.org/10.1371/journal.pmed.1001244.t003

Theme 1. Accessibility and Responsiveness

Six articles documented that a significant proportion of outpatient services in low- and middle-income countries appeared to be provided by the private sector [15] – [18] . However, the percentage of total visits varied substantially across countries and income levels [15] . In Viet Nam, the private sector provides 60% of all outpatient contacts. In India, more than 90% of children affected by diarrhea are taken to private healthcare providers, but the income gradient was not specified among studies reporting this data [17] . Among participants surveyed for HIV testing in 12 African countries, the proportion of patients using the private sector for testing ranged from 3% to 45% [19] .

Several studies disaggregated utilization by income levels, tending to find that the private sector predominantly serves more affluent populations. A widely cited study on access of the private and public sectors was performed by the World Bank in 22 low- and middle-income countries using Demographic and Health Surveys [20] . Although interpretation of the findings varies [5] , [20] , the analysis found that in 19 of the countries studied, both wealthy and poor families received more care from the private than the public sector, but only when the private sector included private drug shops and similar informal providers [21] ; when the composition of the private sector was limited to only licensed and certified healthcare personnel, the public sector provided the majority of care in low- and middle-income countries. However, there were three exceptions: Namibia, Tanzania, and Zambia, where private sectors are majority providers even when only licensed personnel are counted. The percentage of visits to the private sector was lower among the poor than among the wealthy in these surveys, but the difference was not statistically significant.

Additionally, in Colombo, Sri Lanka, where the private sector provided more than a quarter of all childhood immunizations overall, among the wealthiest quartile it provided 72% of immunizations but among the poorest quartile it provided only 3% [16] . In Uganda, 17.4% of women use private clinics or midwives for their family-planning-related medical care due to short distances and low transport costs, according to interviews conducted among 10,706 women, of whom 57% were in the country's lowest wealth quintile [18] .

Few studies have investigated “accessibility” per se (i.e., the ability to access available services). However, wait times were consistently found to be shorter in private sector than in public sector facilities [22] , [23] . One interview-based study in Ghana suggested that waiting times among public sector facilities could be longer for the same condition than private sector facilities by one or two hours [22] . Women living in rural Nigeria also reported preferring private obstetric services to public services because doctors were more frequently present at the time of patient presentation [23] .

Patients tended to report worse hospitality from providers at public than private facilities (13 studies) [24] – [36] . In Bangladesh, for example, public providers ranked lower than private providers on scale-based surveys in which patients assessed the diagnostic explanation given them, courtesy of staff, cleanliness of facilities, capacity building, and the availability of certain medical inputs [36] . A study in India found that patients were seen for longer durations, were more likely to have a physical exam during their visit, and were more likely to have their diagnosis explained to them by private sector physicians than public sector ones [33] . Analysis in several countries suggested that patients in private sector facilities reported preferring the facilities because of shorter waiting periods, longer or more flexible opening hours, and better availability of staff [34] .

Theme 2. Quality of Health Care

Nine retrospective chart reviews and survey-based studies found that diagnostic accuracy and adherence to medical management standards were worse among private than public sector care providers [37] – [45] . Most of these studies examined infectious disease management protocols, including for tuberculosis and malaria [46] . Private practitioners had significantly worse knowledge of correct diagnosis and treatment. Other disease categories showed similar patterns of lower quality in the private sector. In Nigeria, public providers were significantly more likely to use rapid malaria diagnostics and to use the recommended combination therapies than private providers [47] .

Similar poor adherence to guidelines in prescription practices, including subtherapeutic dosing, by private sector providers has been associated with a rise in drug-resistant malaria in Nigeria [47] . Parallel results were reported from Viet Nam [48] . In an analysis of outcome data from 24 countries, children with diarrhea were found to be less likely to receive appropriate oral rehydration salts and more likely to receive unnecessary antibiotics when seeing private providers than when seeing public providers [49] . However, a study of 119 private and ten public health clinics in Uganda found that both private and public providers prescribed antibiotics incorrectly (including not prescribing them when indicated), and in this study public providers were worse in adhering to national malaria treatment standards (14% versus 27%, p  = 0.002) [45] .

Poor adherence to guidelines in prescription practices, including prescribing subtherapeutic doses, failure to provide oral rehydration salts, and prescribing of unnecessary antibiotics were more likely to occur among private than public providers [47] – [49] , although there were exceptions [45] . Higher rates of potentially unnecessary procedures, particularly cesarean sections (C-sections), were also reported at private than at public settings [50] , [51] . One analysis of the Peruvian health system found significantly higher rates of C-sections after the privatization of delivery. The pre-reform rates in the private sector were already higher than the WHO recommended rate of 10%–15%; after reform, the rate exceeded 50%. The same has been found in South Africa, where 62% of women delivering in the private sector had C-sections, compared with 18% in the public sector [51] . Studies in Mexico suggested that fee-for-service payment structures (which are more heavily present in private than in public care delivery settings) incentivized increased C-sections [23] .

Two cross-sectional studies documented a lack of drug availability and service provision at public facilities. A semi-structured questionnaire distributed to 24 health secretariats and directors of 39 city hospitals and 26 referral and teaching hospitals revealed that 76% of state facilities and 67% of city facilities lacked assisted reproductive technologies that were widely available in private sector facilities (though the exact percentage among such private facilities was not evaluated) [52] . In Tanzania, a semi-structured questionnaire distributed to 80 randomly selected patients and 45 health facility personnel staff working in diabetic clinics found that private facilities tend to stock more types of oral hypoglycemic agents than public facilities [53] . However, studies did not make clear whether the additional types of drugs were related to better outcomes or were simply additional brands of equivalent medication on hand.

Some studies of quality of care were performed in the private sector without having a comparative public sector group. Two studies in South Africa found that the majority of private general practitioners were not aware of the recommended medications, doses, or durations for treatment of sexually transmitted infections [54] , [55] . Reviews in Nigeria and Laos reported similarly widespread use of ineffective therapies for malaria in the private sector [56] , [57] . Sexually transmitted disease management in private clinics and drugs shops in Uganda revealed that 93% of cases were not properly managed per national guidelines, and the cure rate was 47% [58] .

Dispensation of unnecessary medications and procedures was also reported to be higher among private sector providers according to four reports based on chart reviews. The most common incidents involved the unnecessary use of antibiotics for treatment of diarrheal diseases and non-complicated acute respiratory infections [32] , [49] . Reports from Africa and Laos suggest ineffective and sometimes harmful pharmaceuticals are being distributed in the private sector [56] , [57] .

Surveys of patients' perceptions of care quality were mixed. While two survey-based studies suggested that patients perceived higher quality among private practitioners, possibly due to frequent prescribing of medications and more time spent with patients [20] , [34] , three interview-based studies suggested that patients perceived public sector healthcare workers as more competent [32] , [59] , [60] .

Theme 3. Patient Outcomes

Public sector provision was associated with higher rates of treatment success for tuberculosis and HIV [61] – [64] as well as vaccination [65] , [66] . For example, in Pakistan, a matched cohort study in Karachi found that public sector tuberculosis care resulted in an 85% higher treatment success rate than private sector care [63] . In Thailand, patients seeking care in private institutions had significantly lower treatment success rates for tuberculosis, which was attributed to a three to five times greater likelihood of being prescribed non-WHO-recommended regimens than in the public sector [61] . In South Korea, tuberculosis treatment success rates were 51.8% in private clinics as opposed to 79.7% in public clinics, with only 26.2% of patients in private clinics receiving the recommended therapy, and over 40% receiving an inappropriately short duration of therapy [62] . Similarly higher rates of treatment failure were observed for private than public system patients on antiretroviral therapy for HIV in Botswana [64] . In India, an analysis of over 120,000 households, adjusted for demographic and socioeconomic factors, found that children receiving private health services were less likely to receive measles vaccinations [65] . Similar findings were reported from Cambodia [66] .

Studies comparing pre- and post-privatization outcomes tended to find worse health system performance associated with rapid and extensive healthcare privatization initiatives. In Colombia, following major privatization reforms in 1993, population vaccine coverage declined for several diseases in the country, and tuberculosis incidence rose significantly [67] . In Brazil, privatization of fertility control services led to increased abortions, sterilization, and improper use of oral contraceptives (obtained without medical consultation), ultimately linked to higher mortality rates among young women [68] . However, a slower pace of privatization of health care services did not appear to correlate with a substantial worsening in patient outcomes among Latin American countries [69] .

Theme 4. Accountability, Transparency, and Regulation

Data on this theme tended to be unavailable from the private sector. No papers were found to describe any systematic collection of outcome data from entirely private sector sources. One recent independent review of Ghana's private sector referred to the private sector as a “black box,” with a dearth of information on delivery practices and outcomes [22] . Tuberculosis and malaria case notification to the public health system was particularly poor among private sector providers as compared to public providers in a number of countries [28] , [48] , [70] . However, while national vital statistics databases collected from public sector clinics and hospitals were widely available, they varied considerably in quality according to external assessments [22] , [71] .

Public–private partnerships also lacked data. A systematic review of data from public–private partnerships (including arrangements among governments and private, for-profit contractors) found few reported data that were of sufficient quality to assess the impact of partnership services and programs [72] . Poor data availability was observed in another systematic collection from several countries' private–public partnerships for sexual and reproductive health services. Most data available showed that after brief training of health providers, provider responses to questionnaires improved in accuracy, but no assessments were made of health outcomes [71] . An exception was a partnership in India that demonstrated increased birth attendant coverage from 27% to 53% over 7 mo among a cohort of 97,000 women [73] .

Several reports observed significant public spending being used to regulate the private sector in order to improve patient care quality, particularly in African countries, and with limited effectiveness [22] , [74] – [76] . The effectiveness of these regulations of the private sector was found to vary, often depending on public monitoring and enforcement [17] , [34] , [77] . Regulations to reduce the sale of unnecessary breast milk substitutes by private drug shops in Laos had limited impact until government inspectors visited sites to ensure appropriate sales and provided sanctions for legal violations [17] . In Indonesia, Kenya, Pakistan, and Bihar, clinical education programs to improve distribution of oral rehydration salts and reduce inappropriate antibiotic prescribing were found to have a greater impact when patients also received education, and when community healthcare workers were involved in monitoring, than when education was given only to clinicians [17] . Reviews in Zimbabwe and Tanzania identified anti-competitive practices and sales of inappropriate drugs [75] ; attempted regulations in Zimbabwe were ineffective [76] . One review in Ghana indicated that the key public agency in charge of such regulation was unable to identify a large number of private providers in order to assess accreditation and quality: 2,612 of 11,430 drug shops were registered but had not received licenses [22] . A private–public partnership in South Africa to educate providers about national guidelines for sexually transmitted disease prevention and control had no effect on practice [77] . In Egypt a comparative assessment of clinical education programs found greater improvements in public sector practices than private sector practices [34] .

Theme 5. Fairness and Equity

Financial barriers to care, particularly user fees, were reported to be prevalent in both private and public systems. A World Bank study in Ghana concluded that there was no systematic evidence indicating whether user fees in the public sector were different than in the private sector [78] ; however, the data presented showed that out-of-pocket user fees for patients were highest for private not-for-profit, lowest for public, and intermediate for private self-financed providers [22] . Hence, the conclusions of the report appear to be disputed by the data within the report.

As noted in the preceding sections, private sector health services tend to cater more greatly to groups with higher income and fewer medical needs (an illustration of the “inverse care law”), resulting in disparities in coverage [35] , [79] – [85] , although findings varied in several cases [86] , [87] . Some studies suggested there was a systematic bias against indigent patients in terms of both quality and access. Exclusion of poor patients by the private sector was observed in South Africa [80] and Paraguay [81] . Poor patients were as likely as wealthier patients to seek care from private providers in Laos, but poorer patients received service from less qualified providers, with limited-quality services (no exam or advice, only medication dispensing) [35] . While most reports described income-based stratification in access, one report described stratification based on gender in addition to income. A nationally representative, cross-sectional, cluster-sample survey of 7,308 children in randomly selected rural and urban populations across Bangladesh observed that over 90% were taken to the private sector. However, when patients arrived at private clinics, children from higher income households and male children were significantly more often ( p <0.001) directed to a licensed provider and treated with oral rehydration solution or an antibiotic than female or poor children [85] .

Several studies suggested that the process of privatizing existing public services increased inequalities in the distribution of services. Analyses of the Tanzanian and Chilean health systems found that privatization led to many clinics being built in areas with less need, whereas prior to privatization government clinics had opened in underserved areas and made greater improvements in expanding population coverage of health services [82] – [84] . Privatization in China was statistically related to a rise in out-of-pocket expenditures, such that by 2001, half of Chinese surveyed reported that they had forgone health care in the previous year due to costs; out-of-pocket expenses accounted for 58% of healthcare spending in 2002 compared with 20% in 1978 when privatization began. The cost burdens of privatization related to an increase in disparities in healthcare coverage and infant mortality between urban and rural areas [79] . One survey-based study using Demographic Health Survey data from 34 sub-Saharan African countries found that privatization was associated with increased access, and reduced disparities in access between rich and poor [86] . A second analysis of the same dataset, however, found no change in inequality in use of modern contraceptives with the expansion of the private sector [87] .

Private contracting and social franchises showed potential for expanding private sector coverage to impoverished groups, although conclusions are tentative because comparisons to the public sector were unavailable. One World Bank study in Cambodia reported improvements in healthcare coverage in poor districts after contracting out services to private companies specifically to increase coverage. When contracts explicitly included targets for reaching the poor, contractors improved health services for the most marginalized groups, although comparison was not made to the results of a similar investment in public sector services [88] . Several related World Bank initiatives took the form of social franchises, in which private providers pay a fee and are provided training, managerial assistance, and certification in a provider network [20] , [89] , [90] . Several case studies of social franchises [20] , [89] , [90] found higher care utilization among the lower socioeconomic groups of private franchisers than of control private clinics for contraceptive use, HIV counseling, antenatal care, and vaccination [17] , [91] , [92] .

Theme 6. Efficiency

Several reports observed higher prescription drug costs in the private sector for equivalent clinical diagnoses [33] , [36] , [53] , [67] , [93] – [96] . In a survey study of prescription costs in India, costs were higher for every class of visit in the private sector [33] . Two-thirds of outpatients in the private sector, compared with one-third in the public sector, received an injection for similar presentations, but the study did not investigate what fraction was unnecessary [33] .

Both generic and brand-name drugs were found to be higher in price in the private sector [96] . Tanzanian private facilities typically used more brand-name oral hypoglycemic agents, but even generic medications were five times higher in price [53] . Similar findings were reported in India [96] . A study in Bangladesh found that private sector healthcare prices in the country—not just those associated with medications—have been growing far above the inflation rate [36] .

There is also evidence that the process of privatization is associated with increased drug costs [36] , [53] , [67] , [93] , [94] , [96] . A study of the Malaysian health system found that increasing privatization of health services was associated with increased medicine prices and decreased stability of prices [93] . Healthcare costs in Colombia rose significantly following privatization reform in 1993, and 52% of capitation fees were spent on administration [67] . Similar privatization in some parts of South Africa were associated with a 13% to 32% cost increase in overall health spending, without associated increases in coverage or indications [94] ; costs of prescriptions were significantly lower in the public sector, likely due to generic substitution, prepackaging of medications, and use of treatment protocols [95] .

Higher drug costs are in part associated with disease complications attributable to delayed diagnosis or incorrect disease management [97] , [98] . In Bolivia, seeking care in the private sector was associated with longer delays in tuberculosis diagnosis and greater costs [97] , [98] . It was estimated that in Mexico, Brazil, and South Africa, unnecessary C-sections increased delivery-related health costs in the private sector by at least 10-fold [23] . In Bangladesh, private contracting of health services appeared to increase costs related to complications and delays in service access [36] .

Several World Bank studies found significant fragmentation in purchasing and distribution across and within the public and private sectors, resulting in higher drug prices and redundant treatments that increase overall healthcare costs [22] , [99] . The absence of reliable distributors for pharmaceuticals in a study in Ghana led to several intermediary groups being used to distribute medications, increasing prices between 5% and 200% [22] . The large number of small-scale hospitals and clinics in some sub-Saharan African countries fragmented delivery, such that patient diagnoses and treatment histories were unavailable between institutions [22] , [99] , often significantly delaying care, and resulting in redundant tests and sometimes administration of incorrect medication to patients. Several private primary care providers reported difficulties referring their patients to public sector secondary care facilities, as public facilities did not accept the diagnoses made by the private providers and often required the patient to restart the consultation process [99] .

Competition between public and private delivery tended to decrease drug prices. One large multilevel analysis of the content and cost of 700 medication transactions observed in 14 private and public settings in Mali revealed that private providers were more likely to prescribe brand-name drugs, injectable drugs, and more antibiotics; however, the availability of drugs in the public sector decreased prices in the private sector [100] .

Contracting of public healthcare services to private providers has also been estimated by the World Bank to reduce costs of and waiting times for contracted services [36] , [101] , although the effects of contracting differ markedly by the type of healthcare service and across countries [17] , [102] . In Cambodia, contracted districts had costs of $22.7 per person per year versus $26.4 among non-contracted districts, although there were no tests of statistical significance [36] . One highly cited secondary analysis reported this outcome as a 17% savings resulting from contracting [101] . Peer-reviewed studies of contracting in Zimbabwe and South Africa found that costs were unchanged by contracting in South Africa but were lower after contracting in Zimbabwe [17] . One review of contracting experience in Madagascar and Senegal found that large expenditure from public sector ministries was necessary to manage and supervise private contracts, increasing overall costs in those two countries by 13% and 17%, respectively [102] .

Other Observed Factors

A few key findings reported in articles did not clearly fit into the WHO health system themes, mainly involving recent reports of complex “competitive dynamics” between private and public health sectors. First, a “crowding out” effect appeared to occur between private and public sector services for expanding delivery. This process involved the transfer of public funds and personnel to private sector development, followed by reductions in public sector service budgets and staff availability. In Ghana, new private services in urban middle- and upper-socioeconomic populations were found to reduce revenues for public sector hospitals that also provided care to poorer populations [22] . At times, however, the process was a passive privatization: public sector funds were increasingly allocated to private–public partnerships without accompanying shifts in demand, so that the public sector's effective budget per patient was reduced. This dynamic was observed in post-apartheid South Africa [103] , as well as in Uganda [104] and Brazil [105] . Public–private partnerships and private contractors were often involved in such scenarios, but did not typically disclose the data necessary to fully evaluate these arrangements.

Public and private sector interactions also had implications for delivery, staffing, and disease control. Interviews of Indian patients suggested that several private practitioners who work in both public and private sectors advised patients to visit their private clinics or requested further payments in order to continue providing care in the public clinic [106] . Doctors tended to migrate towards private sector and urban jobs, depriving the public sector and rural areas of physicians [107] . However, private hospital systems often subsidize or provide healthcare technologies to patients who cannot obtain these services from public hospitals. For example, in Botswana, private hospitals often receive cancer patients from public hospitals that are unable to provide radiation oncology services [78] . In some cases, however, the services in differing sectors undermined performance of one or both sectors. Several studies found that poor reporting of diseases in the private sector impeded public sector control of communicable diseases [28] , [48] , [70] .

Our systematic review of comparative analyses of public and private healthcare systems in low- and middle-income countries found strengths and limitations in both sectors for each of six main WHO health systems framework themes. Private sector healthcare systems tended to lack published data by which to evaluate their performance, had greater risks of low-quality care, and served higher socio-economic groups, whereas the public sector tended to be less responsive to patients and lacked availability of supplies. Contrary to prevailing assumptions, the private sector appeared to have lower efficiency than the public sector, resulting from higher drug costs, perverse incentives for unnecessary testing and treatment, greater risks of complications, and weak regulation. Both public and private sector systems had poor accountability and transparency. Within all WHO health system themes, study findings varied considerably across countries and by the methods employed.

The review has several limitations, which reflect the existing data and literature purporting to compare the healthcare performance of public and private sectors. First, existing studies have focused on isolated topics where data are more abundant, and as a result have overlooked important dimensions of health sector performance. To address this limitation, we drew on a broader range of data, including reports from non-governmental organizations and international agencies like the World Bank. This step was particularly important for acquiring data from the private sector, since such data are relatively unavailable in the peer-reviewed academic literature. Thus, some studies included were not peer-reviewed. Our review involved a detailed analysis of methodological criteria for these studies to ensure they met similar standards of data analysis and reporting as peer-reviewed research. Second, although it was not possible to perform a quantitative meta-analysis because of variations in coding and outcomes, we were able to identify unsubstantiated claims in several cases, which appeared more prominent among non-peer reviewed sources. For example, the World Bank has made strong claims that investing in public–private partnerships will improve efficiency and effectiveness in the health sector [108] , yet several of its publications revealed that these assertions were either unsupported by data or the data was not provided in sufficient detail to pass minimal inclusion criteria required for this review [20] , [78] . Efforts are needed to address potential conflicts of interest of such agencies and their implications for research and data reporting, particularly as their analyses are often very highly cited in the academic literature on health system assessment and performance.

Third, our reliance of the WHO health system themes enabled the analysis to address systematically and comprehensively the existing research on public and private sectors. However, a limitation of the thematic framework, for example, is that several elements of the patient experience in healthcare settings, such as waiting times, are not systematically cataloged in current assessments. This implies that future research in the area should include a focus on how experiential aspects of care are relevant to healthcare seeking and outcomes (such as the likelihood of follow-up among patients requiring return visits) for differently structured care environments. Fourth, the review identified mixed results in several cases and was unable to account for a range of potential modifying factors, partly as a limitation of the broad WHO health system components that do not incorporate contextual factors. For example, treatment of infectious diseases in public settings may be more efficient than in private settings because of higher volume, and greater use of systematized protocols due to that higher volume. Such differences limit the ability of existing work to compare fairly the public and private sector for differing disease categories and in differing social and economic contexts of healthcare delivery.

Although it was not the focus of our research, we observed that some of our findings in low- and middle-income countries mirrored existing evidence from high-income countries. For example, the lack of data from private sector groups was similar to the situation in the UK, where the privately run Independent Sector Treatment Centres was unable to provide healthcare performance data when required [109] . However, our evidence also indicates that contextual factors modify the relationships we have observed, so that it is not straightforward to transpose health system evidence from high-income countries to low- and middle-income countries. Importantly, we observed that regulatory conditions interact with the effectiveness of public and private sector provision, but in low- and middle-income countries regulatory capacity is much weaker. As one example, the reviewed data suggest that systems that incentivize more procedures (rather than better outcomes) tend to lead to inefficiencies and poorer health outcomes. One extensively studied alternative system in high-income countries is pay-for-performance remuneration systems. It remains unclear what effects such programs may have in low- and middle-income countries as compared to high-income countries.

Our study has important implications for future research and policy. Future research is needed to address several important methodological limitations of existing studies. Many analyses were excluded from the review because they lacked a systematic approach to cataloging health system quality. Ideally, analyses should be comparative and should include a “counterfactual” in order to make causal claims about the effects of the particular benefits of providing services in one sector or the other. For example, social franchising to engage private providers in an organized regulatory system, which has been extensively piloted, has yet to be analyzed over the long term using outcome data and a comparison with commensurate investment in public sector development [88] . Studies also need to specify carefully the definition of the private and public sectors. When the private sector included unlicensed physicians, it was found to provide the majority of coverage for low-income groups, but when only licensed providers were included, the public sector was found to be the main source of healthcare provision in low- and middle-income countries. While some commentators report a higher number of absolute healthcare workers in the private sector, and a higher number of visits among the population to the private sector, these observation may be artifacts of improperly coding a large portion of private “providers” who are not actually qualified healthcare personnel, but rather drug store salespeople [1] , [5] . Most studies fail to capture the full scope of effects of reforms on the healthcare system, focusing on an isolated health system component. A reform may enhance public sector performance but compromise the market in the private sector, or vice versa. Standards may need to be developed for health system research for identifying what is “safe” and “effective” overall for patients across socioeconomic strata, just as we do for pharmaceutical safety and efficacy.

Some authors have highlighted the lack of regulatory infrastructure available in low- and middle-income countries to monitor the performance of private healthcare contractors [110] . Despite the lack of data about private sector performance, recent initiatives by the World Bank's International Finance Committee are underwriting the expansion of private sector services among low- and middle-income countries. For example, in sub-Saharan Africa, the International Finance Committee has created a private equity fund to make 30 long-term investments in private health companies. These conflicts of interest pose a potential threat to the validity of World Bank–sponsored studies and raise the need for independent scrutiny.

Our review indicates that current data do not support claims that the private sector has been more efficient, accountable, or medically effective than the public sector [8] . The review also identifies several areas of focus for quality improvement. In the private sector, benefits may accrue from enhancing medical knowledge for appropriate diagnosis and disease management, drawing on specific quality improvement programs for continuing medical education that may serve as models [17] . It is also important to address conflicts of interest from physician-induced demand, particularly when prescribers are also drug store owners. Regulation and consumer education have been more successful than a reliance on clinical education alone in Pakistan and Bihar [17] . In the public sector, quality improvement may need to address incentives to perform at high standards among providers who may not feel threatened by a lack of business in the manner that private practitioners do. One proposed approach is to link provider compensation with results from patient outcomes, weighted by baseline disease risk in the patient population [111] . More generally, policy research needs to determine how targeted interventions might address these core weaknesses among both private and public delivery environments, including the lack of disclosure of outcome and performance data; as a measure of accountability, public transparency can be considered a vital sign of system performance (particularly for those systems receiving public subsidies; [112] ). While there is no clear definition of a “basic minimum dataset” for countries to capture health sector performance, we did notice several common themes in our data review. In many of the countries studied, surveillance of disease treatment outcomes among adults, and particularly noncommunicable disease, was found to be limited. Furthermore, we found further data gaps in health system performance around the issues of waiting times, financing changes (e.g., to further characterize the “competitive dynamics” we described), and outcomes of quality improvement efforts within each sector.

A critical challenge in years to come is how to address competitive dynamics between private and public realms, so that public sector facilities are not stripped of resources that are given to the private sector as subsidies, and so that the ability of public clinics and hospitals to retain skilled healthcare workers is not compromised, especially as both types of systems attempt to coexist in the healthcare delivery environment of low- and middle-income countries. These findings are consistent with earlier findings of an “infrastructure inequality trap” in some countries [103] , in which government funding is increasingly attracted towards private hospitals and away from the public sector hospitals. This occurs when private patients can afford to pay for greater infrastructure at private hospitals. Those hospitals then report greater “absorptive capacity” for future funds, and higher numbers of healthcare personnel, thereby attracting more funding from government institutions, shifting budgets away from public sector facilities that struggle to maintain human and physical infrastructure. Furthermore, we found evidence that many public–private initiatives involve public sector funding being dedicated to monitoring and preventing corruption in the private sector.

Overall, the data describing the performance of public and private systems remains highly limited and poor in quality, suggesting that further investigations should more systematically make data available to track the performance of both public and private care systems before further judgments are made concerning their relative merits and risks.

Supporting Information

Search strategy.

https://doi.org/10.1371/journal.pmed.1001244.s001

PRISMA checklist.

https://doi.org/10.1371/journal.pmed.1001244.s002

Author Contributions

Conceived and designed the experiments: SB JA DS RP. Performed the experiments: SB JA. Analyzed the data: SB JA. Wrote the first draft of the manuscript: SB JA DS. Contributed to the writing of the manuscript: SB JA DS SK RP. ICMJE criteria for authorship read and met: SB JA DS SK RP. Agree with manuscript results and conclusions: SB JA DS SK RP.

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Advantages Of Government Hospitals (Essay Sample)

Hospitals are universally accepted as the place of healing. There are two types of hospitals: a private hospital and a government owned hospital. A private hospital is owned either by family, or a group of companies and are usually quite more expensive in terms of payment than a government owned hospital wherein most of the costing are either free or cheaper than the bills given by a private owned hospital. This essay focuses on the benefits of availing the services of government hospitals.

Availing the services of government hospitals is highly beneficial. Apart from the aforementioned cheaper and/or almost free price, government health care also removes discrimination among patients. Discrimination among patients can come in the form of either racial or financial terms. Racial discrimination in hospitals mainly root from medical givers preferring the patients to have the same “blood” in them wherein they have this mindset that they belong to that country due to same ethnicity, beliefs, and color. Racial discrimination rarely applies to hospitals though; however, financial discrimination is another story.

Having trouble obtaining medical care because some filthy-rich businessman managed to get the health benefit before you did, needed to consult a doctor for a check-up but his professional fee and his prescription medicines are so expensive or ever needed a transplant but you were put at the bottom of the list because you cannot pay up? Government health care prevents such financial discrimination by making sure that medical givers treat all patients equally. By making sure that all patients are treated equally, be it they are financially capable or not, the government can ensure quality healthcare for everyone.

Another advantage of Government health care lies in their health care plan regulation. This health care plan runs on making sure that insurance companies abide by their policies. Health insurance companies usually over-charge consumers and even go as far as deny the patient who availed their insurance ample medical coverage for toxic or chronic diseases, make their insurance too expensive for a middle-class patient to afford, rejection due to pre-medical conditions and technologically advanced medical testing. Unfortunately, privately owned insurance health care companies are difficult, even for the government to enforce their rules and regulations in terms of health care insurance. Government regulated health insurance is a different case than a privately owned one since the government will force insurance companies to be held accountable for any medical infractions as well as guaranteeing that health care is provided to everyone.

An ongoing problem on government health care all around the globe is the quality of the health care itself. Government usually solves this problem by gathering, analyzing, and disseminating information. The government also takes into consideration the specialization of doctors that patients with special and critical conditions need. By prioritizing what medical givers should practice and disseminating information regarding the disease and the proper medication and preventions needed, the government not only advertises a safer environment but better quality health care.

Lastly, access to a far more advanced medical technology set-up, patients are able to access first class equipment. While it is true that some private hospitals have the finest medical equipment: from a CT Scan to the sharpest and sturdiest surgical tools, public health care is also given funds by the government in replacing old technologies with new ones which will not only grant patients who can barely afford expensive medication access but will also be of benefit for all since these modern technologies will be able to help in the identification of diseases which may have not been detectable by old practices and old medical equipment.

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UNMET DEMANDS

Clinicians to stop work at mathari and spinal hospitals, they suffer the highest unemployment rates compared to other health workers..

• Their strike began April  1, but the government has never met their leaders for any negotiations yet Afya house officials met with doctors and nurses.

• KUCO deputy secretary general Austin Oduor led the clinicians weekly protests in Nairobi on Tuesday.

Striking clinical officers have now asked their colleagues to stop working at Mathari hospital and the National Spinal Injury Hospital in Nairobi, where they have been offering services on compassionate grounds.

The Kenya Union of Clinal Officers made this decision to force the government to the negotiating table.

The clinical officers are seeking to sign a comprehensive bargaining agreement that will raise their salaries, and allowances and improve their employment rates.

They suffer the highest unemployment rates among all the other health workers.

Their strike began April  1, but the government has never met their leaders for any negotiations yet Afya House officials met with doctors and nurses.

“Our members have diligently maintained essential services  at  Mathari  Hospital,  Spinal Injury Hospital, Ports Health Authority and other vital institutions. However, after careful consideration and deliberation within our union organs, we have resolved to escalate our actions. Therefore, we hereby order all our members within the respective institutions to join the strike effective Thursday, May 16, 2024,” said Kuco secretary general George Gibore.

They have ten demands that should be “adequately and urgently” addressed.

“We trust that this action will draw attention to the pressing issues faced by our members and lead to meaningful dialogue and resolution,” Gibore said in the letter addressed to Health CS Susan Nakhumicha.

Kuco deputy secretary general Austin Oduor led the clinician's weekly protests in Nairobi on Tuesday.

He said they are demanding enhanced risk allowances of Sh15,000, restoration of Sh105,000 monthly stipend for degree clinical officer interns, which had been reduced to Sh50,000, and comprehensive medical insurance. Diploma interns are paid Sh35,000 a month.

 They are also demanding promotions and the signing of the scheme of service by the Public Service Commission, outlining career progression guidelines.

“We also want the permanent and pensionable employment of the clinical officers on UHC contract, and more employment to end the shortage of clinical officers in public facilities,” Oduor said.

The strike is protected by the courts, which declined the government’s request to declare it illegal last month.

Yesterday, the Council of Governors first met with officials Gibore and chairman Peterson Wachira to try and finds a solution to the strike.

This was the first meeting with the clinicians since their strike began last month.

Kenya has about 32,000 clinical officers who have been registered and licensed to practise by the Kenya Clinical Officers Council.

However, the government has only employed about 7,800 while 800 are on contract.

Clinical officers work both as general practitioners and specialists from referral, specialist consultation, admission to the ward and general treatment services.

Early last month, acting director general for Health Patrick Amoth appeared to justify the government’s indifference to the clinical officers' plight.

Speaking on Citizen TV on April 4, Amoth said clinical officers are not recognised outside Kenya and should therefore go into other careers as a solution to their massive unemployment.

He said they are probably not needed because their training was started as a stop-gap measure when Kenya had a shortage of doctors.

“Is it prudent to continue on that path or we retrace our paths a little bit and help them to progress toward a different career path? Remember clinical officers were a stop-gap by the government to address the shortage of doctors. Now we have 3,000 unemployed doctors. Do we want to continue to produce clinical officers? Or do we retool them to a different path?” he said.

Clinical medicine in Kenya is offered at the diploma level by the Kenya Medical Training College and at the degree level in more than 10 universities.

The diploma programme started at the Kenyatta National Hospital in 1928 and was discontinued in 1952.

The training restarted in 1967 because of a shortage of doctors and has expanded to date.

The training covers medicine, surgery, paediatrics, obstetrics and gynaecology, community health, rural health and health service management, among others.

It is recognised in law and there is a Clinical Officers Council that is charged with training registration and licensing COs. Clinicians fall somewhere between nurses and doctors in the clinical hierarchy and are allowed to perform some invasive procedures.

[PHOTOS] Clinical officers hold demo, demand more pay and allowances

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Victorian budget 2024 confirms delay to Airport Rail Link, net debt still set to grow

The Victorian budget has confirmed delays to the Airport Rail Link, as the state government outlines its plan to tackle the state's rising record debt.

Treasurer Tim Pallas's 10th budget has still contained plenty of spending, with no new major taxes introduced.

Parents will get the biggest budget sweetener, with $400 credits to help with education expenses for children at government schools, as Premier Jacinta Allan tries to focus on families in her first budget in the top job.

Victorian ratepayers have also been asked to chip in through an increase to the fire services levy.

Despite the rhetoric of better economic management, Victoria's net debt continues to climb.

Net debt is now forecast to hit $187.8 billion by 2027-28, when Victorians will be paying roughly $25 million each day on interest payments.

The budget faces a $2.2 billion deficit this financial year but is projected to return to a surplus of $1.5 billion by 2025-26.

The treasurer has defended the budget as one that strikes a responsible balance without taking "the economic momentum out of the economy".

Mr Pallas said his government was focused on moving past COVID debt by reducing net debt as a proportion of the state's economy.

Budget figures show net debt represented roughly 20 per cent of gross state product (GSP) in 2022-23, and is set to climb to 25.2 per cent in 2026-27, before dropping slightly to 25.1 per cent the following year.

When pressed on the impact of that debt on future generations, the treasurer said it was important the figures were viewed in context.

"I can assure Victorians that our priorities are on the commitments we gave them and recognise the material circumstances of the time and do no harm to the continuing growth and resurgence of the Victorian economy," he said.

Mr Pallas said a reduction in government advertising and selling government office spaces were among the measures that would keep government expenditure at an average growth rate of 2.2 per cent per year.

"Pretty profound in anyone's language," he said.

"You haven't seen that in this state for 15 years."

Airport 'stand-off' sees delay of at least four years

Some big-ticket infrastructure items have also had their timelines pushed back, including the Airport Rail Link, which the government has indicated will be delayed by at least four years.

Mr Pallas said that was due to the "stand-off" with the airport over the station's design that was unlikely to be resolved soon .

Melbourne Airport, which has long advocated for an underground station rather than one above ground, responded to Mr Pallas's comments shortly after the budget was handed down.

"Melbourne Airport was part of a consortium that offered up to $7 billion towards an underground airport station and express tracks from Sunshine," a spokesperson for the airport said.

"The state government rejected this. The timing of the project has always been a matter for government."

On Tuesday night, a Victorian government spokesperson said the airport's previous consortium proposal was a "terrible deal" for Victorian taxpayers.

"The proposal would have privatised the Geelong line for 40 years and charged Victorians a fee to access their own rail services," they said.

"Even the former Federal Liberal/National government recognised that this $20 billion proposal did not stack up."

A level crossing removal project for the busy Upfield train line, which runs through Brunswick in Melbourne's inner-north, has also been delayed until 2030.

But $996 million has been set aside to get ready to open the Metro Tunnel rail project and the West Gate Tunnel next year.

The budget also set aside $139 million in a bid to attract and retain more teachers in Victorians schools.

The measure includes $63 million to go towards the mental health and wellbeing of school staff.

The budget allocated $211 million towards interventions aimed at preventing family violence and help victim-survivors.

This includes a further investment in the government's Respectful Relationships program, which has been rolled out at some schools.

But CEO of Sexual Assault Services Victoria Kathleen Maltzahn said the urgency of the situation should have prompted a greater investment.

Credit rating agency says 'thin' forecast surplus key to maintaining AA rating

Credit rating agency S&P Global Ratings downgraded Victoria's credit rating from AAA to AA in 2020 — the lowest of any state or territory in Australia.

The agency said this year's budget confirmed the government's accounts were in "large structural fiscal cash deficit".

"This is the highest among the Australian states and stems from successive operating deficits and its large capex [capital expenditures] since the pandemic hit in late fiscal 2020," the agency said in a statement after the budget was released.

"Debt to operating revenues has almost tripled since this time. Victoria's serviceability costs are also rising.

"On the flipside, we believe Victoria maintains strong access to global capital markets.

"This will allow the government to fund its budget and avoid any acute stress scenario, despite rising interest expenses and market volatility."

The agency said it expected Victoria's AA credit rating would be supported by the state's wealthy and diverse economy, but pressure on the rating could build if the "thin" operating surplus forecast in the budget was not achieved.

State Opposition Leader John Pesutto said the budget was a missed opportunity to make life easier for Victorians and change the direction of the state.

"With record debt, record interest, record taxes, service cuts and poorer outcomes, it's clear Labor cannot manage money and Victorians are paying the price," he said.

Economist says little 'wriggle room' for government if 'things turned sour'

RMIT economist David Hayward said the Victorian government had handed down "another generous budget".

"It's surprised me how much the government has chosen to spend on new output … this is a big-spending budget again," Dr Hayward said.

"The risk with the budget is that they haven't really got much wriggle room if things turned sour.

"I think that what they're betting on is that people will prefer to see the extra spending on things that matter most to them.

"If things do turn sour it might be a different story."

Monash University economist Zac Gross said the budget had demonstrated some spending restraint, but a sustained effort was needed in the coming years.

"Debt payments are reaching record levels," Dr Gross said.

"We are on track as a state to spend more on interest payments than we do on transportation or social services.

"If we want to avoid that fate, we need spending restraint not just today, but for the next few budgets to come."

Worker shortages drive delays across mental health, pre-prep programs

The government will also scrap the COVID-era sick pay guarantee, which was introduced to assist casual workers who needed to isolate while unwell.

As recently as last year, the government had considered extending the scheme permanently through an industry levy, but the budget papers confirmed it would be discontinued.

The government said difficulty in finding workers had also forced it to push back delivery timelines for its pre-prep programs in some areas.

Workforce shortages were also cited as the main reason for the government delaying the rollout of 35 planned walk-in mental health clinics.

Budget papers stated Victoria could not find the additional 2,500 psychologists, psychiatrists and mental health nurses needed to support the services.

But the government is still injecting $10 billion into the healthcare system, including $1.4 billion to progress the delivery of upgrades at the Austin Hospital, Monash Medical Centre and Northern Hospital in Melbourne.

The government has also moved the proposed expansion of the Royal Melbourne and Royal Women's hospital site from Arden to the existing location in Parkville.

The plan to build a new hospital campus near the soon-to-open Arden station was announced in 2022, but according to budget papers, has been deemed "unviable" due to "electromagnetic interference" from trains.

In regional Victoria, $5.4 million has been set aside to build a mental health, alcohol and drugs hub at the Ballarat Base Hospital's emergency department.

Increase in fire services levy and tip fees

The state budget did not contain any major new tax hikes — a move welcomed by the Victorian Chamber of Commerce and Industry.

But the government is asking ratepayers to contribute more to the state's finances through an increase to the fire services property levy.

From July, the median residential property owner will pay an additional $35, while primary production properties will face a $150 rise.

It's also increased the state's waste levy, which currently sits at $129.27 per tonne for metropolitan industrial and municipal waste left at the tip.

From July next year, it will increase to $169.79 per tonne.

The government says a "proportional" increase will also be applied at rural landfills, which attract lower levies than those in the city.

The budget figures also highlighted the extreme difficulty faced by young Victorians seeking to own a home in the state.

Budget analysis highlighted that in the mid-1990s, the average Victorian house price was roughly 3.5 times average household incomes.

But in the last few years, that ratio has doubled, recently peaking at seven times average incomes.

It means the average time taken for 25 to 34-year-olds to save for a deposit has risen from five years in the mid-90s to seven or eight years more recently.

In recognition of this, the government has set aside $700 million for a one-off extension of its Victorian Homebuyer Fund, where it assists homebuyers by taking a stake in the purchase.

But this will be the final investment in the program, before it is replaced by the federal government's Help to Buy scheme .

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