Rationalising health care provision under market incentives: experimental evidence from south Africa

Unnecessary medical treatments place a significant burden on health systems striving for universal health coverage (UHC). This thesis studies inappropriate treatment incentives in the private sector in South Africa, where plans to implement a national health insurance system (NHI) foresee the contracting of private physicians to deliver publicly-funded health care. Private providers are increasingly recognized as necessary partners for UHC success in many low-and-middle-income countries (LMIC). However, aligning the incentives of these actors with UHC and public health goals requires a better understanding of incentive effects in these settings. I conduct two field experiments with incognito standardized patients (SPs), to both evaluate appropriate care provision and experimentally vary the treatment incentives facing private physicians. First, I run a within-subject experiment with 89 private primary care physicians (GPs) in Johannesburg, to investigate the causal impact of improving patients’ financial protection (insurance cover) on physicians’ quality of care delivery. The results suggest that more insured patients receive a higher level of visible clinical effort, but a lower level of technical care quality – including a higher likelihood of inappropriate antibiotic treatment. Second, I use data from the same experiment to evaluate the impact of patient insurance on the quantity and costs of care. I find that more insured patients are more likely to receive unnecessary diagnostic tests and treatment procedures, and receive more and more expensive branded drugs, resulting in significantly higher care costs. The results on antibiotic treatment and drug treatment quantity and costs occurred despite the absence of any financial incentives attached to drug prescribing for GPs, which suggests the presence of alternative motives for physicians’ treatment decisions that might vary with patient insurance – including intrinsic or altruistic motives. Third, I explore the scope for leveraging such intrinsic motivations to improve physicians’ treatment choices. I conduct a randomized (between-subject) experiment with 80 GPs, to evaluate the impact of intrinsic, informational incentives from private performance audit and feedback (A&F) on physicians’ antibiotic treatment choices and care costs. The findings suggest that private A&F can significantly reduce the likelihood of inappropriate antibiotic treatment for common viral infections that present in primary care, without simultaneously reducing appropriate antibiotic use for bacterial infections or increasing other inappropriate drug treatments. However, improved performance on antibiotic use does not coincide with significantly lower treatment costs or any improvements in measured diagnostic effort or accuracy. There is indicative evidence that prescribing norms and perceived patient expectations may play an important role in mediating private physicians’ treatment choices in all three empirical chapters

International Profiles of Health Care Systems, 2011

This publication presents overviews of the health care systems of Australia, Canada, Denmark, England, France, Germany, Japan, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. Each overview covers health insurance, public and private financing, health system organization, quality of care, health disparities, efficiency and integration, use of health information technology, use of evidence-based practice, cost containment, and recent reforms and innovations. In addition, summary tables provide data on a number of key health system characteristics and performance indicators, including overall health care spending, hospital spending and utilization, health care access, patient safety, care coordination, chronic care management, disease prevention, capacity for quality improvement, and public views

Internal report cluster 1: Urban freight innovations and solutions for sustainable deliveries (1/4)

Technical report about sustainable urban freight solutions, part 1 of

Social health insurance systems in European countries: the role of the insurer in the health care system: a comparative study of four European countries

This paper examines the role of social health insurance in four European countries: Germany, Switzerland, France and the Netherlands. It attempts to elucidate the organisational structure, regulation and management of the social insurance schemes, as well as the relationships between the insurers, providers and consumers in the various countries with the aim of uncovering some of the inherent strengths, weaknesses and tradeoffs hich exist within social insurance systems.health care systems, Europe, insurance

Is decentralization good for development? Perspectives from academics and policy makers.

Decentralization research has become more quantitative and formal over the past two decades. But as technical rigor has increased, the focus of research has narrowed to decentralization’s effects on particular policy variables, leaving aside larger, more nuanced and complex questions of crucial importance to policymakers contemplating reform. This book seeks to return attention to issues like this that rank among policymakers’ first concerns, but are methodologically difficult to answer. We do this by marrying the insights and experience of senior policymakers involved in driving decentralization forward at the highest levels, with academics working at the forefront of the field in economics, politics, and development and policy studies. This chapter introduces the book by analyzing the following questions: Why do politicians decentralize in the first place? How can reform be made politically feasible? How can decentralization lead to improved development outcomes? Do municipalities compete amongst themselves, and what effects might this have on public policy and services? Will decentralization promote clientelism or broad-based development? And finally, will decentralization strengthen or weaken developing states? The evidence presented in the book provides a firm basis for concrete answers to all of these questions, allied to specific policy advice for aspiring reformers

Consultancy to progress hospital in the home care provision: Final report, CHERE Project Report No 13

In July 1998, the Commonwealth Department of Health and Family Services commissioned the Centre for Health Economics Research and Evaluation (CHERE) to identify and document Hospital in the Home (HITH) care models nationally and internationally. The purpose of this consultancy was to examine the appropriateness of this form of care for acutely ill patients and to make recommendations about how to increase the utilisation and cost effectiveness of services. Hospital in the Home is emerging internationally and within Australia as a viable alternative form of provision of acute care. The benefits of HITH have generally been seen in terms of its capacity to provide a cost-effective and acceptable alternative to hospital inpatient care, which reduces pressure on hospital beds. However, so far there has only been limited evaluation to lend support to these claims. Over the past decade a wide range of hospital in the home programs have been introduced across the Australian health care system. These programs have often emerged in response to local factors and have a range of different purposes, funding and organisational arrangements, and varying levels of success. In some states hospital in the home has been formalised into a program, whereas in other parts of Australia the introduction of HITH has been left to local decision makers. Thus, the experience of HITH has been extremely variable. It is appropriate at this stage to draw together information about what services are available, how acceptable these services are and what they have achieved. This information is important for determining the future directions of HITH in Australia, as well as providing a valuable resource for service providers and policy makers.Hospital in the home, Australia