|
|
|
Index - Major Sections
Site Map
Product and Services _______________ Index - Same Level Subject
Index - Child Subjects |
Introduction Health care services are the easiest to market and the hardest to control of any consumer product. This results from a variety of factors – ethnicity, poverty, geographical location, age, gender, lack of employment, unavailability of services to treat particular problems and, bad planning and management of services (Cassels, 1995). Health Education and Health knowledge must also be included in this list. Indicators are often developed to determine to what extent the government is pro-poor versus pro-rich. This is calculated by taking the ratio of the government expenditures that go to the poor versus that that goes to the rich. However, this may be a distortion of what is actually taking place. What should be measured is the “services” that are provide to the poor versus the “services” that are provided to the rich. Although the total expenditures for the rich may be higher, the number, type of services, and cost of proving those services may be the same. InHCc’s research in Mexico has shown that while the “rich” may pay out of pocket $50 for a physician visit, the “poor” will pays $5 out of pocket for the same physician visit. It is called marginal pricing, as long as the health care professional feels that it is “worth the effort”, he will charge what the market will bear. The same services that are supplied to the poor may cost less to the government than those same services supplied to the rich. The fact that a "Health Minister" changes the new stable for his wife's horses as a "new Clinic" doesn't help evaluate healthcare either.
Perceived Quality of Care Although many researchers collect statistics such as the “population within x kilometers of a health facility”, it doesn’t tell you if the population uses these health facilities or if the facility has the resources that address the needs of this population. In many case studies and in InHCc’s research (Bangladesh, Guatemala, Honduras, Mexico), it has been shown that the population will by-pass government clinics (or certain other NGO organizations) and walks many miles to get to another healthcare facility. The population has a very clear "perception" of the optimal size for a clinical facility and that of the “perceived quality” of care that is given by any one clinic. If the population views the health care facility as supplying poor quality of care or having bad management…they will not come.…even if the health care organization does in reality gives the best care! Our research also shows that the client is willing to pay more for a “specialist” even if they do not need a specialist…and even if they do not have the economic resources to do so! Facilities that are not visited or that operates inefficiently mean very little if these are counted in the “being within x kilometers”. Rural environments present unique challenges for health care access. Facilities are staffed by physicians with very little experience, have no medicines, and have no means of referral of the patient not only does very little good but it also waste resources that can better be used for better care. Building Healthcare centers that are effectively stock with resources such as drugs and healthcare professionals is required. Resources Available Population per doctor is also a statistic that has little meaning. The number of doctors that are trained for the “type” of services demanded by this population may be more significant. As Cassels stated, it is more important to relate the services available to the particular problem. In one country studied, the average number of patients seen by a government physician may only be 10 patients, while the average number of patients seen by a private physician may be close to 30 and in other countries, a public health physician may see 30 patients while the private physician sees only 10! There is no relating of “clients need” to productively levels. In one study by InHCc, the number of days that the patient remained in the hospital was directly related to how many patients were waiting to get into the hospital (InHCc, Bangladesh, 1998). If health care operated under true market forces, in which the population knows the value of what they are buying, there may be a business argument for offering better quality care. But purchases of health care usually don’t know and so private health care providers can make more money by offering “show-time” services, i.e. offering “quality service.” Even worse, where employers have the ability to choose the health care organization that supplies health care services to their employees…the employer will generally choose the cheapest! The National Health Accounting Project attempts to match the source of funds of individuals for stated services, however, the data used for these calculations are often collected from very unreliable sources and the results are often only available years after the event…of no use to management. In summary, the National Health Accounting Project is only as good as the data that goes into the calculation… (See full discussion on the InHCc Web site). Economic AccessEconomic Access means that the costs of health care is affordable to the population. One way to make health care more affordable is to give the Client “only” what he needs, when he needs it efficiently and at a “fair price.” It is not always about “Reducing Costs”, especially if it means reducing the services that a patient must have. Increasing “Economic Access” can come about by the health care organization operating more efficiently and preventing the “leakage of funds” from the organization. A former Director of Social Security (responsible for 80% of the health care of the country) stated to InHCc that approximately 30% of the health care resources were stolen. By operating more effectively and efficiency, the prices changed to clients may be reduced or more services may be provided for the same cost to the client. An “average cost per hospital visit” (or some other average cost per event) is an often used statistic that has little meaning for management. It is only the marginal costs of a health care service that has any meaning. The problem is that most health care organizations do not operate like a well-managed business organization. Neither do healthcare organizations collect data to determine marginal cost nor do they even know how to use marginal costs to manage the provision of services. There are very few studies that relate the “source” of the household’s payment for health care services to the actual payment for the services. The “out-of-pocket” (versus insurance, social security, etc) expenditures may not tell the true story. For example, as stated previously, Baum & Senski (1989) reported that 60% of Thai farmers who sold land were forced to do so because of the costs of ill-health! InHCc has had one manager of a “charitable” fund of the Switzerland government tell them that “if the patient can pay, they can afford it.” Increase in “Economic Access” can come about by the health care organization operating more efficiently and preventing the “leakage of funds” in the organization. By reducing the costs of services, the prices changed to clients may be reduced or more services may be provided for the same cost. An “average cost per hospital visit” (or some other average cost per event) is an often used statistic that has little meaning for management. It is only the costs to selective household members, of a particular economic class, and for a specific health care procedure that has any meaning. Subsidies to ClientsSubsidies to clients are ineffective. If you cannot determine who needs help, you cannot give help to the right people. Subsidies through “income” testing and waivers for the poor are often ineffective. This arises from the lack of financial data on individual clients and in determining who the “poor” are. Clients often lie about their income either to get the waiver or to prevent people from knowing how poor they may actually be. In these cases, either the system loses too much money by paying for services to individuals that are able to pay themselves, or the very poor clients do not get the benefits that they need. In order to evaluate objectively the economic status of a family unit, information is needed from a variety of sources. These sources include not only the income of a family but also its assets, liabilities and its potential for earnings. EducationEducation can either decrease the cost of health care or increase the cost of health care but very few studies have been performed to determine the education-cost benefit effect. Better educated individuals often know more about health care and take better care of themselves…thus lowering health care costs. However, better educated individuals also use the health system more often…thus rising health care costs.
Along with rising consumerism, Individuals have high expectations of healthcare...and it is growing exponentially. Education can often play an important role in access to health care. Clients not knowing about health care services or knowing about their own health status are just as important factors in determining access to services as either money or transportation. As the population in developing countries becomes more familiar with using health care facilities, the service rates (and costs) will increase exponentially to governments. It has yet to be determined if the overall improvement in health care status will lower the long term costs. At the same time, if the population is educated to recognize when they should go to a health care unit and how to care for themselves during minor illness the service rates, the cost of care will decrease exponentially. Studies have shown that approximately 80% [at least] of the clients that visit a health care unit will get better wither he goes to the unit or not. Beginning able to recognized the difference of when a person should go and should not go is the purpose of Health Education. Better educated individuals often know more about health care and take better care of themselves…thus lowering health care costs. However, better educated individuals also use the health system more often…thus rising health care costs to public health systems. As an example, research results relate that individuals in urban areas are more likely to report a health problem than their rural counterparts and that individuals living in better-off households were more likely to report a sickness or injury than individuals living in poorer households. It is unknown if these results show that higher educated wealthier individuals “know how to take better care of themselves” (which the studies assume) or rather if these individuals just “know how to use the system” and overuse it. It has yet to be determined if the overall improvement in health care status will lower the long term costs. Very few studies have been performed to determine the education-cost benefit effect. In fact, the data goods like that the higher education of the population….the higher the per-cost expenditure for healthcare. In order to prevent this exponential growth in costs to the health system, Health Care Education should be “informed” education. Education should be targeted to individual populations that increase the health status of that population proportionally more than the increase in the usage of health care services. Only by having complete data can this targeting be developed and implemented. It has been shown that without extensive follow-up to staff training, that staff very soon return to the same level of work within a short period of time. Training needs to be continuously monitored…computer applications have the ability to repeatedly reinforce training through help menus, “warnings”, and the ability to audit. InHCc has shown that having a “monitoring” system, physicians provide better care as measured by: time spent with the patient, better history taking, more appropriate diagnoses based on the symptoms, and more appropriate medications and treatments based on the symptoms. TransportationIn many cases, the development of a good transportation system, instead of creating more hospitals, may be more cost effective. Not only does this increase access to services, but it also provides access to other services. By increasing the demand at existing health care organizations, the average cost of client care is decreased by the organization taking advantage of the economics of scale (assuming the health care organizations can operate efficiently).
Rural environments present unique challenges for health care access. There are often shortages of medical personnel in rural areas, as well as transportation and distance barriers to care and an increasing economic destabilization of rural health care services. Rural practice locations typically generate lower income for the physician and have fewer and older technology resources than urban and suburban locations. Modern medical school graduates are rarely well prepared to practice in rural environments. Consequently, rural communities suffer chronic physician shortages. People with financial resources and the ability to travel tend to use distant urban centers even for less complex needs. The majority of patients admitted to rural hospitals are either too frail to withstand travel to distant hospitals or cannot afford either the travel or the cost of care in urban areas. Closures leave the very old, the disabled, and the poor with no access to hospital inpatient care, and the entire community is left with no access to urgent or emergency care. Many rural areas have little or no transportation and very poor people have no way of paying even if there was. While there may be a local government clinic, if there is no means of transportation of a referral to a second level medical center, the local clinic does little good. In many cases, the development of a good transportation system, instead of creating more hospitals, may be more cost effective. Not only does this increase access to services, but it also provides access to other services. By increasing the demand at existing health care organizations, the cost of client care is decreased by the organization taking advantage of the economics of scale (assuming the health care organizations can operate efficiently). Equitable CareWhile many “Recommendations” state that equitable care should be provided according to medical need…this will never happen as long as there is any chance to “purchase” additional health care. While it sounds good in a report, does anyone really believe that it will happen? As long as their is "private practice" there will be no equitable care! Remote and Isolated Locations In many poorer and remote areas, the fact remains that this population have much worse health and nutrition status. In addition, this health status is general caused by social and economic problems that are generally not taught in medical school. These groups need "better" physicians and nurses, not new graduates just out of medical school. These areas also need a "better" than average ratio of workers to clients, bother because of their heavy disease burden and because treatment and education of these people take longer than normal. Problems
Solutions
|
|
|