Kassean & Juwaheer ~ 26

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]

Le Meridien Hotel, Mauritius, 24-27 August 2010 1


mailto:[email protected]

mailto:[email protected]

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



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.



http://www.gov.mu/portal/site/mohsite/menuitem.d08bfdb108ac5aae3c2690f6a0208a0c/

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



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;



· 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:



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.



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



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.



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



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



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:



· 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


-0.5

2

-1.2

3

Mea

nSco

re

4.08

3.40

4.61

4.63


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

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.



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


Kassean & Juwaheer ~ 26

Documents

le meridien

international

normal working

health care

health care

established

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private medical