Comparing Healthcare in Private Clinics v/s Public Hospital Services Sector

Comparing Healthcare in Private Clinics v/s Public Hospital Services Sector Hemant Kassean* University of Mauritius Faculty of Law and Management Reduit, MAURITIUS E-mail: h.kassean@uom.ac.mu T D Juwaheer University of Mauritius Faculty of Law and Management Reduit MAURITIUS Email: roubina@uom.ac.mu Le Meridien Hotel, Mauritius, 24-27 August 2010 1

Comparing Healthcare in Private Clinics v/s Public Hospital Services Sector Paper type: Survey Abstract Purpose In Mauritius, the state provides free health care services throughout the country to all its population. It also has a well established private sector. Public v/s private healthcare is a topic that often generates passionate debates. The purpose of this paper is to explore some of the lived experiences of patients in public hospitals v/s private clinics. Design/methodology/approach A survey was conducted using a representative sample of 300 patients using a face to face interview who had had experience of the private sector as well as the public sector in the last fourteen months. Findings People tend to have a preference for either public hospitals or private clinics. With higher levels of disposable income and availability of affordable health insurance policies, more and more people are taking private insurance health cover. People opted for public hospitals because they were generally close by and easily accessible, hospitals care and treatment are free and they are better equipped to deal with emergencies. Long waiting time, unprofessional attitude of some staff members, poor hygiene conditions are often cited for choosing a private clinic instead of public hospitals. Other key differences are discussed. Implications for managers and practice - These findings can provide the basis for further research so that appropriate strategies can be devised to improve the health care services in both the public and private sector. Keywords: Private health care, Public health care, Mauritius. *corresponding author Le Meridien Hotel, Mauritius, 24-27 August 2010 2

Background Mauritian Health Care System The future prosperity of Mauritius depends on the good health of the people. For further progress, we must increasingly ensure that our people are fit and well. Better education and better health are the twin pillars of sustainable economic and social development. Hence, Health systems are crucial to the healthy development of individuals, families and societies everywhere. They provide the crucial interface between life-saving, life-enhancing interventions and the people who need them. Health systems thus deserve the highest priority in any efforts to improve health or ensure that resources are cost-effectively used. Reeves and Bednar (1993). Mauritius provides state health services throughout the country free at the point of use to all its 1.2 million people. It also has a well-established private sector. In the island of Mauritius, health services are provided mainly through 13 hospitals of which 5 are specialized ones with a total of 3,500 beds and seventeen nursing homes (private clinics) with a total of 582 beds. The number of contacts with government preventive and curative health services, which includes attendances for the treatment of diseases and injuries at outpatient departments of hospitals, mediclinics, area health centres, community health centres, and ayurvedic clinics, together with admissions and attendances at hospitals for other services such as haemodialysis, diet clinic and physiotherapy was 8.4 million in 2008 with a daily average of around 23,000. http://www.gov.mu/portal/site/mohsite/menuitem.d08bfdb108ac5aae3c2690f6a0208a0c/ / The Private Health Care Sector According to the Private Health Institution Act (1989), Nursing Homes means any premises used or intended to be used for the reception, lodging and care or treatment of any person suffering from any infirmity or convalescing from any sickness or injury, other than a hospital. In the Mauritius, Private Clinics are incorporated within Nursing Homes (Health Statistics Annual, 2004) and are one of the main providers in the health care system of Mauritius besides the public health care sector. Providers operating in the private sector and who benefited from households' out-of -pocket payments during FY 2001/02 were: private clinics, medical private practitioners, including Government medical practitioners who are also allowed to practice in the private sector after normal working hours, private dental practitioners, other practitioners, traditional medicine practitioners, dispensing chemists (i.e. private pharmacies) and providers not specified by kind. Le Meridien Hotel, Mauritius, 24-27 August 2010 3

Source: NHA Health Accounts (2006) Table1.1: Households out-of-pocket expenditure by Type of Private Providers How were households' out-of-pocket payments distributed across the different types of providers? Table 1.1 illustrates the distribution of household out-of-pocket payment made directly to private health providers. The significant chunk of 41.0 per cent of total households' out-of-pocket expenditure was incurred on fees paid to medical practitioners practising in the private sector, as well as those public medical officers who are allowed to undertake private practice after normal working hours. This was followed by 32.5 per cent on the purchase of pharmaceutical products. Private dental practitioners received 12.2 per cent, whereas private clinics were paid approximately 8.7 per cent of total household out-of-pocket payment. Traditional medical practitioners and other practitioners were paid 0.8 per cent and 4.3 per cent respectively. The findings of the NHA Study (2006) highlight, amongst others, the major health spending of the private sector, including households. These evidence-based data indicate that there is a solid and healthy private health sector in the country despite the availability of free high quality care in the public health sector. The NHA findings testify the potentials of the private health sector to further invest and improve health care. Besides, in relation with Government's strategies to transform the country into a medical hub and promote health tourism, the NHA data give a clarion call to the private health sector to expand and diversify further, especially in the field of high-tech medicine. Literature review Le Meridien Hotel, Mauritius, 24-27 August 2010 4

Most health care systems involve a mixture of public and private provision. The health care services in Mauritius are financed by general taxation. In the Mauritian Health Care System, the physicians have the opportunity to work in the private sector - we observe that a substantial share of the physicians spend time in both sectors. For instance, in Mauritius, like in the UK most private medical services are provided by physicians whose main commitment is to the public health care system. The UK Monopolies and Merger Commission (1994) estimated that about 61% of the NHS consultants had significant private work. According to Johnson (1995), physician dual practice is common in many countries like, for instance, France, Spain, Portugal, and the Scandinavian countries. In this paper, we analyse the patients perceptions of healthcare between public and private health care provision. Notably, a physician dual practice introduces close links between the public and the private sector on both the demand and the supply side. In particular, physicians may shift patients seeking public care to their private practice, and they can allocate their labour supply according to which sector that provides the higher benefit. Patient orientated health care system: Many health care organisations, like many private businesses, historically have seen patients as passive recipients of services or products (Morgan and Murgatroyd, 1994). As the experts, senior managers have thought of themselves as at the top of their organisation's hierarchy, while customers/patients were at the bottom. In contrast, patient-oriented organizations elevate patients to the top position. In patient-oriented health care, patients and their satisfaction are considered first and foremost at every point in the planning, implementation, and evaluation of service delivery (Edmunds et al., 1987). Patients are the experts on their own personal circumstances and wants (Morgan and Murgatroyd, 1994). Patient preferences should guide every aspect of service delivery, from clinic hours to counseling techniques to contraceptive decision-making. Patients satisfaction is created through a combination of responsiveness to the patient's views and needs, and continuous improvement of the healthcare services, as well as continuous improvement of the overall doctor-patients relationship. Challenges in healthcare in developing countries: There is a need to find a way to achieve better health care quality that is appropriate (Zineldin, 2006). It is important to start with an understanding of the real situation. Some common features of the health care challenges in many developing countries according to Øvretveit (2004) are: Lack of knowledge about quality ideas, methods and results. Lack of skills in using the methods or in implementing programmes; Le Meridien Hotel, Mauritius, 24-27 August 2010 5

Many personnel are low paid and de-motivated and see no personal or other advantages to spending extra time working on quality improvements: the benefits for them are not clear; A low level of training and professionalism for most health practitioners, who are not supervised, are low-paid and rely other sources of private income; and The lack of management training and a culture with a power structure which would be threatened by lower levels making changes and taking more control of their services, or by the establishment of a strong line management structure and process. Methodology The key objectives of the study were to determine whether there was a market for the private health care sector and how this sector compared with the public health care sector. A sample of 300 patients who had previously had an inpatient experience at the 17 private clinics/and various public hospitals in the last fourteen months were interviewed using a face to face interview. A convenient sample from general medical, surgical and orthopaedic, maternity wards were used based on the number of beds in those different wards over a period of five weeks. A comparative analysis of patients experiences were then carried out between the private and public health care sector. Findings Attendance at Mauritian Public and Private Health Care Institutions: Le Meridien Hotel, Mauritius, 24-27 August 2010 6

Health Care Institutions 71% 19% 10% Public Hospitals Private Clinics Both Figure 1.1: Attendance at private clinics and public hospitals. Figure 1.1 illustrates that the majority of respondents (71%) have attended both the Public and Private Health Care institutions. While 19% of respondents have attended private Health Care services, the remaining 10% benefited from the Public Health Care services only. It is important to note that a higher percentage of patients have received only Private Health Care services only as compared to the percentage of respondents who have attended only Public Health Care institutions. 1.2 Likeliness to choose a Public Hospital for health care services in the future: In the figure overleaf, the 19% of N/A represents the percentage of respondents who attended only private health care institutions in Figure 1.2. As a result they are not likely to choose a Public Hospital. The majority of respondents (50%) are likely to choose a public hospital for health care service in the future. In contrast, 31% are not willing to choose a public hospital for health care service in the future. Le Meridien Hotel, Mauritius, 24-27 August 2010 7

Likeliness to choose Public Hospital 19% 50% 31% N/A Yes No Fig 1.2: Patients Likeliness to choose a Public Hospital for health care services in the future Table 1.1 Reasons for Patients preference for Public Hospitals over Private Clinics: The table below explains the reasons for patients to prefer public hospitals to private clinics. Reasons CODE Public Hospitals are better equipped A1 Public Hospitals are affordable / cheaper A2 Public Hospitals cater for most / all aspects of health Care A3 Public Hospitals offer better service quality A4 Public Hospitals' medical staff (doctors & nurses) are available on a 24 hr basis A5 Public Hospitals' medical staff (doctors & nurses) are more knowledgeable / A6 experienced Public Hospitals' medical staff (doctors & nurses) are professional A7 Public Hospitals' medical staff (doctors & nurses) are caring A8 Others A9 It is to be noted that this question is eligible only for patients likely to choose a Public Hospital for health care services in the future. The 69% of N/A observed in Table 1.1 is representative of the percentage of respondents who attended only private health care institutions (19%); and the percentage of patients who are not likely to choose a Public Hospital for health care Le Meridien Hotel, Mauritius, 24-27 August 2010 8

services in the future (50%). As a result, these patients have no likely reasons to prefer public health care services to private health care services. Some of the most common Other reasons are: Hospital is near / easily accessible Hospitals are free In emergency, hospitals are better Preference for Public hospitals over Private Clinics 70.0 60.0 50.0 % 40.0 30.0 20.0 10.0 0.0 A1 A2 A3 A4 A5 A6 A7 A8 A9 Reasons Yes No N/A Figure 1.3: Reasons for patients preference for public hospitals over private clinics It can be observed that the majority of respondents (25.7%) prefer public hospital services because Public Hospitals are affordable / cheaper (A2). While 13.0% of patients have a preference for public hospitals because Public Hospitals' medical staff (doctors & nurses) are available on a 24 hr basis (A5), 9% and 8.3% of patients have the same preference because Public Hospitals are better equipped (A1) and Public Hospitals cater for most / all aspects of health Care (A3) respectively. Four highest rated reasons identified by patients for their preference for public health care services. Le Meridien Hotel, Mauritius, 24-27 August 2010 9

Table 1.2 Why would patients not come to a public hospital: The table below identifies possible reasons why patients would not like to be admitted in public hospitals of Mauritius. Reasons CODE Poor service quality B1 Poor Admission procedures B2 Unreliable medical staff (doctors) B3 Unreliable nursing officers B4 Poor Ward / Hospital Environment B5 Poor Patient Facilities / Amenities B6 Poor Discharge Planning & Coordination B7 Others B8 It is to be noted that this question is not eligible for patients who have attended only private health care institutions. Hence the 19% of N/A is representative of the 19% of Respondents who attended only private health care institutions in Table 1.2. Some of the most common Other reasons are: Long waiting time Bad behaviour of staff Lack of hygiene Reasons for not choosing Public Hospitals 60.0 50.0 40.0 % 30.0 20.0 10.0 0.0 B1 B2 B3 B4 B5 B6 B7 Reasons Yes No N/A Le Meridien Hotel, Mauritius, 24-27 August 2010 10

Figure 1.4: Reasons for patients preference for private clinics over public hospitals. The majority of respondents (58.7%) would not opt for public hospital services because of Poor service quality (B1). While 56.7% of patients would not choose public hospitals because of Poor Ward / Hospital Environment (B5), 55.7% and 44.7% of patients express the same intentions towards the public health care services because of Poor Patient Facilities / Amenities (B6) and Poor Admission procedures (B2) respectively. These were the four highest rated reasons identified by patients for not choosing public health care services. 1.5 Patients Worst / most bothering experience about at the clinic : % 10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 Patients' Worst Experiences 3.3 7.0 3.3 4.3 3.3 1.0 1.3 10.0 3.0 5.7 2.7 1.7 H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 H11 H12 Health Care Experiences Table 1.3: Patients Worst Health Care Experience of last stay at clinic Most Valuable Experience Code Most Valuable Experience Code Strict visiting hours / Relatives not No proper assistance H1 H7 allowed to stay Money related matters - Expensive / Nurses - not helpful / H2 Money minded / Overcharged bill / H8 unprofessional / inexperienced No value for money Doctors - absent during emergency / more regular visits / unprofessional Disturbance / No privacy / Noise Slow and poor Discharge / Payment procedures Waiting time - treatment / medicine H3 Poor facilities/amenities - toilet / bathroom / telephone / newspapers H9 H4 Poor menu / food H10 H5 H6 Improper treatment / diagnosis / medication Poor management / Poor admission process / No professionalism H11 H12 Le Meridien Hotel, Mauritius, 24-27 August 2010 11

Unfortunately, patients suffered from bad health care experiences as well. Table 1.3 illustrates the patients worst health care experiences during their stay in private clinics. The top five major issues addressed are as follows: 1) Money related matters - Expensive / Money minded / Overcharged bill/no value for money - 10.0% 2) Nurses - not helpful / unprofessional / inexperienced - 7.0% 3) Poor menu / food - 5.7% 4) Disturbance / No privacy / Noise - 4.3% 5) No proper assistance - 3.3% As a result, there are indications that private clinics need to improve so as to convert patients worst health care experiences to positive ones. Table 1.3 Reasons for Patients preference for Private Clinics over Public Hospitals: The table below identifies likely reasons for patients preference for private clinics over public hospitals. Reasons CODE More Trust C1 More flexible and personalised C2 More personal involvement in own care C3 Attitude of Medical Staff & Nursing Officers (More hospitable, courteous, attentive, C4 reliable and always ready to help) Institution Premises are more hygienic and homely C5 Reasons CODE Institution Premises are homely C6 Better Patient Facilities and Amenities - better food quality, better comfort, etc C7 Better access to medical treatment C8 Better medical follow up C9 Better technical care (surgery, specializations, etc) C10 Better complaint management system C11 Others C12 The Top Five highly rated reasons explaining patients preference for private clinics over public hospitals are as follows, in descending order: Le Meridien Hotel, Mauritius, 24-27 August 2010 12

Better Patient Facilities and Amenities - better food quality, better comfort, etc (C7) - 77.7% Institution Premises are more hygienic and homely (C5) - 75.7% Attitude of Medical Staff & Nursing Officers (More hospitable, courteous, attentive, reliable and always ready to help) (C4) - 71.7% More personal involvement in own care (C3) - 69.7% More flexible and personalised (C2) - 69.0% % 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Preference for Private Clinics over Public Hospitals C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12 Reasons Yes No Figure 1.6: Reasons for patients preference for Private Clinics over Public Hospitals Some of the most common Other reasons are: Rapid service delivery Relatives can stay over Service delivered is much better value for money Concluding remarks Le Meridien Hotel, Mauritius, 24-27 August 2010 13

Overall Service Quality Gap Score Mean Score 5.00 4.00 3.00 2.00 1.00 0.00-1.00-2.00 4.63 3.40-1.23 4.61 4.08-0.52 Public Health Care Sector Private Health Care Sector Health Care Sector Mean Expectation Scores Mean Perception Score Mean Gap Score Figure 1.7: Overall Service Quality Gap Score comparison in Mauritian Health Care Sectors A diagrammatic summary for both health care sectors is provided in Figure 1.7 above. This study shows that the overall expectations of patients are not currently being met by either the public or private health care sector. However, Patients dissatisfaction is lower and service quality is higher in the private health care sector compared to the public health care sector. There is room for both sectors to evolve and with more disposable income becoming available to Mauritian households, the private sector is likely to grow further in the future and Appollo hospital is a prime example. However, patients are becoming increasingly aware of their rights and standards of care that they can expect, and therefore both sectors have to put quality at the top of their agenda. This will engender competition between the various private clinics and further comparative research work between private and public sector healthcare can assist in improving standards in general. References UK Monopolies and Mergers Commission. Private Medical Services: A report on the agreements and practices relating to charges for the supply of private medical services by NHS consultants. Cm 2452. HMSO: London, 1994. Johnson N (1995) Private Markets in Health and Welfare: An International Perspective. Berg Publishers Ltd.: Oxford. Le Meridien Hotel, Mauritius, 24-27 August 2010 14

Edmunds, M., Strachand, D., Vriesendorp, S. (1987), Client-responsive Family Planning: A Handbook for Providers, Pathfinder Fund, Watertown, MA Health Statistics Annual 2004 (Ministry of Health and Quality of Life) Morgan, C., Murgatroyd, S. (1994), Total Quality Management in the Public Sector: An International Perspective, Open University Press, Buckingham National Health Accounts (2006), Financial Year 2001 / 2002, (Ministry of Health and Quality of Life) Øvretveit, J. (2004), "Formulating a health quality improvement strategy", International Journal of Health Care Quality Assurance, Vol. 17 No.3, pp.368-76 Reeves, C.A., Bednar, D.A. (1993), "What prevents TQM implementation in health care organisations?", Quality Progress, Vol. 26 No.4, pp.41-4 The World Health Report, (2000), Evaluation Method Guidelines for Maternal and Child Health, Family Planning, and Other Health Services, World Health Organization, Geneva Zineldin, M. (2006), The quality of health care and patient satisfaction: An exploratory investigation of the 5Qs model at some Egyptian and Jordanian medical clinics, International Journal of Health Care Quality Assurance, Vol. 19, pp. 60 92 Le Meridien Hotel, Mauritius, 24-27 August 2010 15