Private Hospital Review, 2011 (Independent Private Health Subsector)

Private Hospital Review, 2011 (Independent Private Health Subsector Review) 
 

The majority of diseases especially malaria and HIV/AIDS episodes in Uganda are initially treated in Private Hospitals and private health clinics. For most diseases the public hospitals are sometimes sparsely distributed. Prevention and treatment is therefore cannot be substantially scaled up without considering how best to make use of private hospitals and private health Clinics. Private health clinics are popular because they are often cheap, as partial doses are sold; they are accessible; there is improved interaction between consumers and providers; they harmonize the demand and supply forces in the Private Sector. However, consumers are sometimes unable to assess the technical quality of services, with the result that they place more weight on aspects of perceived quality, such as the interpersonal skills of providers, and the comfort of the environment in which treatment occurs both of which may be unrelated to technical competences. Relatively few approaches to supporting advocacy for consumers in their use of the private health services have been used to improve consumer information and awareness.  

There is need to strengthen institutions like private hospital associations that can give consumers greater authority to challenge care of poor quality services. Consumers often lack institutional structure to seek redress when they have victims of medical malpractices or negligence in the private health sector. The dominance of private health provision in Uganda's Health System makes it vital to consider more understanding of the private health consumer and devise appropriate strategies.  Currently the problem lies most in the Private-for-profit (PFPs) hospitals and clinics and the following issues have been noted;  

1. In Uganda, private hospitals are mainly faith-based non-profit hospitals and private-for-profit (PFP) hospitals mostly owned by private individuals and companies.

2. The Ministry of health allocates funds from its annual budget to faith-based hospitals through their respective medical bureaus (e.g UPMB, UCMB, UMSC orthodox and others) but little or no funds are allocated supported to Private-for-profit (PFP) health hospitals yet both sub-sectors help in access and improving the health service delivery in Uganda. In fact most faith-based hospitals operate under a Not-for-profit (NFP) status but surprisingly charge almost the same commercial health fees / charges like the private-for-profit health centers.  If it is done (financial support to PFP subsector), it should be done uniformly not on opportunistic grounds.

3. Private hospitals and clinics need to benefit from the government's national health programs to increase public health access and awareness but they are often ignored during the planning of these national health programs.   PFP’s Hospitals and health clinics are not often involved in the planning stage to implementation and evaluation of most of the immunization programmes.

4. Sometimes the health ministry plans to extend these public health programs (like the H1N1 flu testing ) and treatment facilities to the private sector, but the response from private hospitals and laboratories have been often poor. Probably the lack of interest of the private sector is primarily due to the huge investment required to set up and operate such facilities and the strict infection control norms which are to be followed.

5. During a study by Uganda National Association of Private Hospitals (UNAPH), some PFPs queried the liability of a patient vaccinated by a private provider i.e. in regard to any defect of the vaccines or adverse drug effects of the vaccine on the patient. They wondered who takes the liability in case of adverse effects / defects, where in that case they are agents of the Government. (!!!???)

6. The health ministry may keep an increased watch on infectious diseases through involvement of private hospitals and clinics under their Disease Surveillance programs to strengthen the reporting system of infectious diseases which have the potential to turn into epidemics.
7. Private hospitals sometimes refuse to treat emergency injuries and cases within their vicinity where they are encouraged to do so. However, question arises who carries the risk if doctors of private hospitals who pass away while treating epidemics like H1N1 or SARS!
   
   
8. Private hospitals need to be regulated like the public hospitals through their self regulatory trade associations as the government plans to expand the role of the private sector.

9. Some citizens think "private" means "better" but practically there is eminent neglect and low compliance to standards. There are many reasons to go private. It may save potentially long delays on public hospitals waiting lists and can ensure a high standard of service during your treatment. Once you decide to go private you have a choice about which hospital consultant you want to see, etc

10. Private health sector should harness the successes rather than the failures of their sector as there is an apparent admiring of the private sector.

11. Private hospitals are lightly regulated in Uganda. Some of them are very good, but at their worst they are unsafe, lacking basic standards in monitoring and emergency care. In some cases, some of them the priority appears to be three-star hotel comfort as if patients are taking a holiday. In contrast, the best public hospitals can offer sustained and sophisticated medical treatment delivered by staff who are motivated by values other than the making of money. There is still scope for significant improvements in the way many private hospitals are run which exposes the need for a significant strengthening of the regulations governing private hospitals.

12. The health ministry has medical councils to regulate private hospitals and clinics, but apparently they need more teeth. It is already clear what teeth they need. MOH regulatory councils' criteria and standards for the opening of private health facilities are applied and respected by private health players. However, they have insufficient resources to conduct ongoing supervision and monitoring of private actors. If the private sector is to play a bigger role in the National Health Service Delivery, private hospitals should be governed by the same regulations as the state-owned hospitals through their self-regulatory trade association / subsector association. There is nothing wrong with the private sector becoming self regulated. This can save the Government and taxpayer the formation of crisis units and crisis authorities/departments.  In other countries it plays a constructive role through their private hospital associations.  But in Uganda, where some players are used to a relatively light regulatory touch, the players insist on the old version. 

13. In the past, Private-for-profit (PFPs) hospital regulation has been uncoordinated resulting from a fragmented web of different professional associations which needed a holistic approach so as to fully meet the needs of the community. Through dialogue and the use of self-regulatory mechanisms and other tools, public policy could influence the practices and development of the private role in health so that it serves national health goals and objectives.

14. One way to encourage people to build private hospitals is to provide dedicated land and conditions in urban areas. i.e If commercial land tenders are used, people will prefer to build offices or residential buildings, but now there is a need to limit development to key infrastructures like hospitals.  Poor investment levels arise from lack of knowledge and frameworks, leading to lack of access to finance and expertise for growth and expansion.

15. Private hospitals and clinics are expected to expand their role and capacity in public health or preventive medicine and are expected to grow and develop far beyond any expansion. Private health clinics and centers are effective providers because their approach to healthcare is local and targets the unique and diverse health needs of the population they serve. They are responsive to the patient population and culturally appropriate.

16. Sometimes there is an apparent donor distortion whereby efforts to integrate service supervision and monitoring in the private health sector is sometimes distorted by donors, some donors and other bodies prefer  working with individual consultants or consultancy firms or NGos for some program interventions instead of working with the relevant line private-for-profit sector trade associations or representative frameworks / organizations which could run the same program with a long-term sustainable approach and a health system strengthening component  / structure . This distorts private health priorities, for example, HIV/AIDS funds can also be used to strengthen general health services, even while ensuring care and support for AIDS patients. There is need to integrate HIV/AIDS funds and other donor funds into strengthening the general health services. Improving the health system will have an impact on a range of killer diseases, including HIV/AIDS.

17. There is lack of agreed measurement standards, accreditation and credible analysis within the PFP sub-sector, giving rise to misrepresentations and misunderstandings that hamper efforts to develop solutions to the problems facing the sector. We suggest that effective reforms be provided by widely accepted, accurate healthcare data measurement procedures, guidelines and definitions. The private hospital sector is unified in calling for the introduction of standardized definitions and measurement criteria to form the basis for all future industry evaluations.

18. The Quality of Private Healthcare in Uganda highlights key areas of the clinical governance systems, processes and measures utilized by the private hospital sector. Soon it will make reference to the proposed Accreditation and Survey Guide to provide data to assist in assessments of quality and compliance.
    

19. It has been observed that Hospital Pharmacy Ownership encourages efficiencies in the private hospital sector. It is critical that each private health center has a pharmacy on its premises, operated and controlled by a qualified pharmacist.

20. There is need for Code of Ethics for Private Hospitals (PFP sector) which will be monitored and implemented by UNAPH. This will reflect the sector’s commitment to ethical standards in delivering quality healthcare. The Code of Ethics will guide the private hospital sector through the Uganda National Association of Private Hospitals. This will be in the spirit of self-regulation, showing the organization’s commitment to ethical standards, in all aspects of the profession.

21. The private hospital sector would like to respond to the growing demand to assist indigent patients with emergency medical and hospital services, irrespective of their ability to pay, demonstrating the sector’s commitment to good corporate citizenship. Vehicle accidents with injuries and fatalities have increased substantially in recent years. Hospital services expenditure in relation to trauma, and particularly road accidents, was historically borne by the government. However, Effective PPPs are needed to strengthen the entire healthcare system and reduce road and other accidents. Where a health center would claim reimbursement from the Road Accident program as there has been an increased use of the private hospital sector for emergency hospital services.
    

22. Private Hospital Sector (PFP sub-sector) regulation has been fragmented as a result of a fragmented web of programs and UNAPH is trying to close this gap. Unfortunately, few people in the public policy sphere seem to recognize that this is a fundamental problem which needs a remedy.

23. The private hospital sector continues to invest in facilities, advanced medical technology and infrastructure. Some individual hospitals and health centers have made substantial investments in designing and creating systems and processes to manage and measure the quality of care. 

24. PPP and PPI initiatives present opportunities to strengthen the entire healthcare system and reduce the fragmentation in healthcare service delivery.

25. Many PFP private Health Centers have been ignored in HMIS and do not effectively contribute to the HMIS process. Most PFPs do not appreciate the importance of HMIS. Some of them look at HMIS as a Ministry of Health issues, which implies that they do not have much interest in it. The issue of who is accountable and responsible for the data also comes up and it is found that no one feels so. Since there is no single person answerable, data is usually misplaced, inaccurate, omitted and hence the validity and reliability of the data is affected.

26. During our review continuing and persistent concern was expressed over   the relationship between public and private health entities and the apparent conflict of interest which arises when individuals employed in the public sector are permitted to engage in private practice. The focus of our attention is on the extent to which such developments affect the promotion of private health sector programs, performance levels and clarity of policy on multijobholding in Uganda.

The information contained in this report has been compiled and is presented in a spirit of constructive engagement. We understand that the issues that currently characterize the healthcare debate can be contentious, and we welcome constructive Discourse to find solutions to the challenges in Uganda’s healthcare, and to take up the opportunities to extend the benefits of good health to all Ugandans.