kassean & juwaheer ~ 26
TRANSCRIPT
International Research Symposium in Service Management ISSN 1694-0938
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: [email protected]
T D Juwaheer
University of Mauritius
Faculty of Law and Management
Reduit
MAURITIUS
Email: [email protected]
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International Research Symposium in Service Management ISSN 1694-0938
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
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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.
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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
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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;
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· 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:
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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.
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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 /
experiencedA6
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
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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 PrivateClinics
70.0
60.0
50.0
40.0
%
30.0
20.0
10.0
0.0A1 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.
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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.
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
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
medicine H6 Poor management / Poor admission
Payment procedures H5 Improper treatment / diagnosis /
bathroom / telephone / newspapers H9
allowed to stay H71.
7
1.31.0
2.7
5.7
3.0
4.3
3.3
3.3
3.3
7.0
10.
0
40.0
% 30.0
20.0
10.0
0.0B1 B2 B3 B4 B5 B6 B7
Reasons
Yes No N/A
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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”:
Patients' Worst Experiences 10.0
9.0
8.0
7.0
6.0
% 5.0
4.03.0
2.0
1.0
0.0H1 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
No proper assistance H1 Strict visiting hours / Relatives not
Nurses - not helpful /unprofessional / inexperienced H2
Money related matters - Expensive /Money minded / Overcharged bill /No value for money
H8
Doctors - absent duringemergency / more regularvisits / unprofessional
H3 Poor facilities/amenities - toilet /
Disturbance / No privacy /Noise H4 Poor menu / food H10
Slow and poor Discharge /
medication H11
Waiting time - treatment /process / No professionalism H12
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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,
reliable and always ready to help)C4
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:
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· 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%
Preference for Private Clinics over PublicHospitals
90.0
80.0
70.0
60.0
%50.0
40.0
30.0
20.0
10.0
0.0C1 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
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-0.5
2
-1.2
3
Mea
nSco
re
4.08
3.40
4.61
4.63
International Research Symposium in Service Management ISSN 1694-0938
Overall Service Quality Gap Score
5.00
4.00
3.00
2.00
1.00
0.00
-1.00
-2.00Public 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
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Publishers Ltd.: Oxford.
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