government hospital essay

Essay on Government Hospital

Students are often asked to write an essay on Government Hospital in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

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100 Words Essay on Government Hospital

Introduction.

Government hospitals are medical facilities run by the state. They provide healthcare services to all, particularly focusing on the underprivileged and those who cannot afford private hospitals.

These hospitals offer a range of services including general medicine, surgery, maternity care, and emergency services. They often have specialized departments like cardiology, neurology, and orthopedics.

The major benefit of government hospitals is their affordability. They provide free or low-cost treatment, making healthcare accessible to everyone.

Despite their benefits, government hospitals face challenges like overcrowding, lack of advanced equipment, and sometimes, shortage of staff.

Government hospitals play a crucial role in society. They need continuous improvement and support to serve the public better.

250 Words Essay on Government Hospital

Government hospitals play a pivotal role in providing healthcare services to the public, especially in developing countries. These institutions, funded by the state, aim to offer affordable and quality healthcare to all, irrespective of their socioeconomic status.

The Significance of Government Hospitals

The importance of government hospitals cannot be overstated. They serve as the primary healthcare providers for the majority of the population, particularly the economically disadvantaged and those residing in remote areas. With their wide reach and subsidized services, they ensure that healthcare is not a privilege but a right for every citizen.

Challenges Faced by Government Hospitals

Despite their noble intentions, government hospitals often grapple with numerous challenges. These include inadequate funding, shortage of skilled medical personnel, and insufficient infrastructure. These issues often translate into long waiting times, compromised patient care, and a general perception of inefficiency.

Improving the Efficacy of Government Hospitals

Addressing these challenges requires a multi-pronged approach. Increasing budgetary allocations for public health, implementing robust recruitment and training programs for medical personnel, and investing in infrastructure development are some of the key steps. Moreover, leveraging technology for better management of resources can significantly enhance the efficiency of these institutions.

In conclusion, government hospitals are instrumental in ensuring that healthcare is accessible and affordable for all. While they face several challenges, strategic planning and investment can significantly improve their performance, thereby strengthening the overall public health system.

500 Words Essay on Government Hospital

Government hospitals are public health facilities primarily funded and managed by the state or national government. They are integral components of a nation’s healthcare system, providing affordable and often free medical services to the public. However, their efficiency and effectiveness have been a subject of debate, underlined by concerns over quality of care, infrastructure, and resource allocation.

Role and Importance of Government Hospitals

Government hospitals play a crucial role in providing healthcare services to the underprivileged and marginalized sections of society. They are often the only accessible healthcare facilities for people living in remote and rural areas. They also serve as training grounds for medical professionals, fostering the development of healthcare skills and expertise.

Despite their importance, government hospitals face numerous challenges. These include inadequate infrastructure, shortage of medical personnel, and insufficient funding. The high patient load often leads to overcrowded wards and long waiting times, compromising the quality of healthcare. Moreover, the lack of advanced medical equipment and technology can limit the scope of treatment options available to patients.

Quality of Care in Government Hospitals

The quality of care in government hospitals is a contentious issue. While some hospitals maintain commendable standards, others fall short due to resource constraints and management inefficiencies. The perception of subpar service in government hospitals has led to a preference for private healthcare among those who can afford it. However, it is essential to note that many government hospitals deliver critical services, including emergency care, childbirth, and disease control, often in challenging circumstances.

Reforms and Improvement Strategies

Addressing the issues plaguing government hospitals requires comprehensive reforms and strategies. These could include increased funding, improved management practices, and the adoption of modern medical technologies. It is also crucial to focus on capacity building to ensure a sufficient number of trained healthcare professionals. Public-private partnerships could be explored as a means to leverage the efficiency of the private sector while ensuring the accessibility and affordability of public healthcare.

In conclusion, government hospitals are an essential part of a nation’s healthcare system, particularly for the underserved sections of society. While they face significant challenges, these can be addressed through strategic reforms and investments. The aim should be to ensure that these hospitals can deliver quality healthcare to all, thereby playing their part in achieving the broader goal of universal health coverage.

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Essay on Hospital

500 words essay on  hospital.

Hospitals are institutions that deal with health care activities. They offer treatment to patients with specialized staff and equipment. In other words, hospitals serve humanity and play a vital role in the social welfare of any society. They have all the facilities to deal with varying diseases to make the patient healthy. The essay on hospital will take us through their types and importance.

Types of Hospitals

Generally, there are two types of hospitals, private hospitals and government hospitals. An individual or group of physicians or organization run private hospitals. On the other hand, the government runs the government hospital.

There are also semi-government hospitals that a private and organization and government-run together. Further, there are general hospitals that deal with different kinds of healthcare but with a limited capacity.

General hospitals treat patients from any type of disease belonging to any sex or age. Alternatively, there are specialized hospitals that limit their services to a particular health condition like oncology, maternity and more.

The main aim of hospitals is to offer maximum health services and ensure care and cure. Further, there are other hospitals also which serve as training centres for the upcoming physicians and offer training to professionals.

Many hospitals also conduct research works for people. The essential services which are available in a hospital include emergency and casualty services, OPD services, IPD services, and operation theatre.

Importance of Hospitals

Hospitals are very important for us as they offer extensive treatment to all. Moreover, they are equipped with medical equipment which helps in the diagnosis and treatment of many types of diseases.

Further, one of the most important functions of hospitals is that they offer multiple healthcare professionals. It is filled with a host of doctors, nurses and interns. When a patient goes to a hospital, many doctors do a routine check-up to ensure maximum care.

Similarly, when there are multiple doctors in one place, you can take as many opinions as you want. Further, you will never be left unattended with the availability of such professionals. It also offers everything under one roof.

For instance, in the absence of hospitals, we would have to go to different places to look for specialist doctors in their respective clinics. This would have just increased the hassle and waste energy and time.

But, hospitals narrow down this search to a great level. Hospitals are also a great source of employment for a large section of society. Apart from the hospital staff, there are maintenance crew, equipment handlers and more.

In addition, they also provide cheaper healthcare as they offer treatment options for patients from underprivileged communities. We also use them to raise awareness regarding different prevention and vaccination drives. Finally, they also offer specialized treatment for a particular illness.

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Conclusion of the Essay on Hospital

We have generally associated hospital with illness but the case is the opposite of wellness. In other words, we visit the hospital all sick and leave healthy or better than before. Moreover, hospitals play an essential role in offering consultation services to patients and making the population healthier.

FAQ of Essay on Hospital

Question 1: What is the importance of hospitals?

Answer 1: Hospitals are significant as they treat minor and serious diseases, illnesses and disorders of the body function of varying types and severity. Moreover, they also help in promoting health, giving information on the prevention of illnesses and providing curative services.

Question 2: What are the services of a hospital?

Answer 2: Hospitals provide many services which include short-term hospitalization. Further, it also offers emergency room services and general and speciality surgical services. Moreover, they also offer x-ray and radiology and laboratory services.

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Open Access

Peer-reviewed

Research Article

Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review

* E-mail: [email protected]

Affiliations Department of Medicine, University of California, San Francisco, California, United States of America, Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California, United States of America, Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom

Affiliation Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America

Affiliation Tri-Institutional MD-PhD Program, Weill Cornell Medical College/Rockefeller University/Sloan-Kettering Institute, New York, New York, United States of America

Affiliation Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America

Affiliations Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom, Department of Sociology, Cambridge University, Cambridge, United Kingdom

• Sanjay Basu, 
• Jason Andrews, 
• Sandeep Kishore, 
• Rajesh Panjabi, 
• David Stuckler

• Published: June 19, 2012
• https://doi.org/10.1371/journal.pmed.1001244
• Reader Comments

Introduction

Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.

Methods and Findings

Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of “private sector” included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. “Competitive dynamics” for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.

Conclusions

Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.

Please see later in the article for the Editors' Summary

Citation: Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D (2012) Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review. PLoS Med 9(6): e1001244. https://doi.org/10.1371/journal.pmed.1001244

Academic Editor: Rachel Jenkins, King's College London, United Kingdom

Received: January 18, 2012; Accepted: May 8, 2012; Published: June 19, 2012

Copyright: © 2012 Basu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: No direct funding was received for this study. The authors were personally salaried by their institutions during the period of writing (though no specific salary was set aside or given for the writing of this paper).

Competing interests: The authors have no competing financial interests. SB, JA, SK and RP are employed at academic medical centers, which receive public sector research finances but also receive revenue through private sector fee-for-service medical transactions and private foundation grants. RP serves on the board of a nonprofit organization (Tiyatien Health) that provides health services in Liberia with approval from and in collaboration with the government and through receipt of private foundation funding, but has received no compensation for this role. SB and JA serve on the board of a nonprofit organization (Nyaya Health) that provides health services in rural Nepal using funds received from both private foundations and the Nepali government; they have also not received compensation for these roles.

Abbreviations: C-section, cesarean section; WHO, World Health Organization

Editors' Summary

Health care can be provided through public and private providers. Public health care is usually provided by the government through national healthcare systems. Private health care can be provided through “for profit” hospitals and self-employed practitioners, and “not for profit” non-government providers, including faith-based organizations.

There is considerable ideological debate around whether low- and middle-income countries should strengthen public versus private healthcare services, but in reality, most low- and middle-income countries use both types of healthcare provision. Recently, as the global economic recession has put major constraints on government budgets—the major funding source for healthcare expenditures in most countries—disputes between the proponents of private and public systems have escalated, further fuelled by the recommendation of International Monetary Fund (an international finance institution) that countries increase the scope of private sector provision in health care as part of loan conditions to reduce government debt. However, critics of the private health sector believe that public healthcare provision is of most benefit to poor people and is the only way to achieve universal and equitable access to health care.

Why Was This Study Done?

Both sides of the public versus private healthcare debate draw on selected case reports to defend their viewpoints, but there is a widely held view that the private health system is more efficient than the public health system. Therefore, in order to inform policy, there is an urgent need for robust evidence to evaluate the quality and effectiveness of the health care provided through both systems. In this study, the authors reviewed all of the evidence in a systematic way to evaluate available data on public and private sector performance.

What Did the Researchers Do and Find?

The researchers used eight databases and a comprehensive key word search to identify and review appropriate published data and studies of private and public sector performance in low- and middle-income countries. They assessed selected studies against the World Health Organization's six essential themes of health systems—accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency—and conducted a narrative review of each theme.

Out of the 102 relevant studies included in their comparative analysis, 59 studies were research studies and 13 involved meta-analysis, with the rest involving case reports or reviews. The researchers found that study findings varied considerably across countries studied (one-third of studies were conducted in Africa and a third in Southeast Asia) and by the methods used.

Financial barriers to care (such as user fees) were reported for both public and private systems. Although studies report that patients in the private sector experience better timeliness and hospitality, studies suggest that providers in the private sector more frequently violate accepted medical standards and have lower reported efficiency.

What Do These Findings Mean?

This systematic review did not support previous views that private sector delivery of health care in low- and middle-income settings is more efficient, accountable, or effective than public sector delivery. Each system has its strengths and weaknesses, but importantly, in both sectors, there were financial barriers to care, and each had poor accountability and transparency. This systematic review highlights a limited and poor-quality evidence base regarding the comparative performance of the two systems.

Additional Information

Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001244 .

• A previous PLoS Medicine study examined the outpatient care provided by the public and private sector in low-income countries
• The WHO website provides more information on healthcare systems
• The World Bank website provides information on health system financing
• Oxfam provides an argument against increased private health care in poor countries

One longstanding and polarized debate in global health concerns the appropriate role and balance of the public and private sector in providing healthcare services to populations in low- and middle-income countries [1] . In recent years, disputes between the proponents of private and public systems have become particularly heated, as the global economic recession that began in 2007 has placed major constraints on government budgets—the major funding source for healthcare expenditures in most countries ( Figure 1 ) [2] . The International Monetary Fund has recommended that countries increase the scope of private sector provision in health care as part of loan conditions [3] , often to reduce government debt [4] . Criticizing such efforts, the international nonprofit organization Oxfam, in its report “Blind Optimism,” concluded that “to achieve universal and equitable access to health care, the public sector must be made to work as the majority provider” [5] . The World Bank responded that it seeks “more pragmatic approaches that build on what is available” by engaging with the private sector in countries where public sector services perform poorly [6] ; the Center for Global Development similarly argued that the Oxfam report “ignored the informal sector,” and that poor people “want to go” to private providers and will “persist in doing so” [7] .

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n  = 190 countries for which data are available. Source: [114] .

https://doi.org/10.1371/journal.pmed.1001244.g001

Generally, this debate has been divided between those seeking universal state-based healthcare availability and those advocating for the private sector to provide care in areas where the public sector has typically failed. Private sector advocates have pointed to evidence that the “private sector is the main provider,” as many impoverished patients prefer to seek care at private clinics [1] . They have suggested that the private sector may be more efficient and responsive to patient needs because of market competition, which they indicate should overcome government inefficiency and corruption [8] . In contrast, public sector advocates have highlighted inequities in access to health care resulting from the inability of the poor to pay for private services. They have noted that private markets often fail to deliver public health goods including preventative services (a “market failure”), and lack coordinated planning with public health systems, required to curb epidemics.

Both sides claim their critics are “ideologically biased” [9] , [10] and selectively draw on case reports to defend their viewpoints [5] , [7] . However, significant conflicts of interest may apply to both groups [11] , as large private international contractors, insurance firms, and non-governmental organizations may benefit from expanding the role of the private sector, while academics who rely on state-funded grant proposals may gain resources from a greater public sector role.

Crucially needed to inform this debate is a systematic review of existing evidence. As Hanson and colleagues note, “A strengthened evidence base on the performance of the public and private health sectors is essential to guide decision-makers towards policy choices that are appropriate for their contexts” [11] . However, in practice, studies comparing the performance of private and public sectors are difficult to implement, for several reasons. First, healthcare services are not universally dichotomized between public and private providers, as some practitioners participate in both state-based and privately owned healthcare delivery systems, and many systems are dually funded or informal. A wide range of arrangements exist for how such expenditures are spent in public versus private clinics, hospitals, and informal settings (see Box 1 for definitions). One example of this complication is the role of informal payments in public facilities. These private–public interactions confound a simplistic comparison between private and public systems. Second, state-based healthcare services and private services have coexisted in many low- and middle-income countries for decades; most countries have a large fraction (but not all) of healthcare expenditures paid for by the state, with most of the remainder paid for by households [12] . In this context, simply defining what is private or public is not straightforward. Private providers are heterogeneous, consisting of formal for-profit entities such as independent hospitals, informal entities that may include unlicensed providers, and nonprofit and non-governmental organizations.

Box 1. Different Public and Private Healthcare Delivery Agents in Low- and Middle-Income Countries

Multinational and national for-profit corporations: for-profit group practices, sometimes associated with hospitals.

Formal individual private providers: individual physicians or other healthcare providers operating in smaller scale healthcare facilities or private pharmacies.

Informal for-profit providers: unlicensed, unregulated providers including shop owners, “injectors,” traditional healers, and birth attendants.

Not-for-profit providers: civil society, non-governmental, and faith-based groups, charities; and community and social enterprises, with varying degrees of regulation and oversight.

Public hospitals, health centers, and clinics: county- and district-level hospitals and clinics, with varying degrees of accessibility and user fees for patients, often having providers that also participate in private sector healthcare delivery.

Public–private partnerships: International or national associations that have varying degrees of for-profit or nonprofit status, or collaborations between for-profit and government/nonprofit entities to deliver services. Also have varying user fees for patients and varying levels of public subsidization for delivering healthcare services.

Although these debates have been highly visible, there is a dearth of reviews on the topic. An initial search of prior systematic reviews and meta-analyses in the PubMed database revealed one recent review, evaluating 80 field-based studies that directly and simultaneously compared service quality in ambulatory public and private care clinics [1] . The analysis found that private outpatient clinics often had better drug supplies and responsiveness than public clinics, but the analysis did not assess other dimensions of health system performance (such as accessibility). The review excluded studies of hospitals, case reports, intervention studies (such as how a sector responded to quality improvement programs), or statistical studies of population-level data.

The aim of the current study is to evaluate available data on public and private sector performance across the key domains of health systems competencies. Our goal is to understand how the private or public nature of a given healthcare delivery institution may impact core healthcare delivery goals. We systematically review published data and studies of private and public sector performance in low- and middle-income countries against six health systems themes used by World Health Organization (WHO), adapted from the 2000 World Health Report [13] . The six themes are as follows: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency [13] ( Table 1 ).

https://doi.org/10.1371/journal.pmed.1001244.t001

Search Strategy

We searched for primary literature in eight major databases using the indexed and free-text terms “private sector,” “privatization,” “public-private sector partnerships,” and “public sector” in various combinations, as described in Text S1 . Because much of the discussion and data collection on this topic has been performed outside of academic circles by international agencies and non-governmental groups, we supplemented the database search by conducting the same keyword searches on the websites of the WHO library database WHOLIS, the World Bank Documents and Reports repository, the United Nations Children's Fund, the United Nations Development Program, the Bill & Melinda Gates Foundation, the Global Fund to Fight AIDS, Tuberculosis and Malaria, Oxfam International, and the Kaiser Family Foundation Global Health Division. The search terms included studies in English, French, Italian, Spanish, Portuguese, or Russian, published from 1 January 1980 through 31 August 2011.

Study Selection

All titles and abstracts found by the search strategy were filtered for relevance to the study objective. Studies must have included data on a population in at least one low- or middle-income country, defined by the 2010 World Bank criteria of having current per-capita gross national income less than or equal to US$12,275 [14] . The full texts of potentially relevant articles were subject to the inclusion criteria listed in Table 2 to ensure they met basic minimum methodological standards. Qualitative studies were included if they specified a systematic methodology for interviews, focus group analysis, historical or political science analysis, or ethnographic observation (see Text S2 for the PRISMA checklist).

https://doi.org/10.1371/journal.pmed.1001244.t002

Data Extraction and Analysis

A data extraction method was designed by three reviewers (S. B., J. A., and D. S.). J. A. extracted the data using a preestablished standard data entry format into a database, with verification by S. B. to ensure consistency of coding. Standard data describing each study were also extracted, including the country where the study was performed, study period, study methodology, number of included participants, primary and secondary outcome measures and end points, and study limitations. Where disclosed, we noted the study funders and agencies. Disagreements between the two reviewers were resolved by consensus among all authors.

The data synthesis was structured into six themes from the updated WHO framework for health system assessment (see Table 1 for themes, subthemes, and indicators used to assess each theme) [13] . Relevant data that did not fall into one of these themes was separately included in the analysis in an “other factors” category that is discussed following the principal results. Reports containing information relevant to more than one theme were included in all related thematic areas. We did not perform further subanalysis of the highest quality studies as the authors could not agree to a vote-counting approach that would apply across the quantitative and qualitative methods and the six WHO themes captured in literature using different types of outcome variables.

The study selection process is shown in Figure 2 as a PRISMA flow diagram. Of the 1,178 potentially relevant unique citations from all literature searches, 102 studies met the inclusion criteria. Key characteristics of the included studies are summarized in Table 3 . Fifty-nine studies were empirical research studies and 13 involved meta-analysis, with the rest involving case reports or reviews. One-third of studies were carried out in the WHO-defined African region ( n  = 32) and another third in the Southeast Asian region ( n  = 34); most were published after 1990. We found that about nine out of ten studies directly compared quality of care in public versus private systems or assessed the demand for or utilization of services; the remaining studies examined drug availability or affordability or compared the cost and efficiency of services.

https://doi.org/10.1371/journal.pmed.1001244.g002

https://doi.org/10.1371/journal.pmed.1001244.t003

Theme 1. Accessibility and Responsiveness

Six articles documented that a significant proportion of outpatient services in low- and middle-income countries appeared to be provided by the private sector [15] – [18] . However, the percentage of total visits varied substantially across countries and income levels [15] . In Viet Nam, the private sector provides 60% of all outpatient contacts. In India, more than 90% of children affected by diarrhea are taken to private healthcare providers, but the income gradient was not specified among studies reporting this data [17] . Among participants surveyed for HIV testing in 12 African countries, the proportion of patients using the private sector for testing ranged from 3% to 45% [19] .

Several studies disaggregated utilization by income levels, tending to find that the private sector predominantly serves more affluent populations. A widely cited study on access of the private and public sectors was performed by the World Bank in 22 low- and middle-income countries using Demographic and Health Surveys [20] . Although interpretation of the findings varies [5] , [20] , the analysis found that in 19 of the countries studied, both wealthy and poor families received more care from the private than the public sector, but only when the private sector included private drug shops and similar informal providers [21] ; when the composition of the private sector was limited to only licensed and certified healthcare personnel, the public sector provided the majority of care in low- and middle-income countries. However, there were three exceptions: Namibia, Tanzania, and Zambia, where private sectors are majority providers even when only licensed personnel are counted. The percentage of visits to the private sector was lower among the poor than among the wealthy in these surveys, but the difference was not statistically significant.

Additionally, in Colombo, Sri Lanka, where the private sector provided more than a quarter of all childhood immunizations overall, among the wealthiest quartile it provided 72% of immunizations but among the poorest quartile it provided only 3% [16] . In Uganda, 17.4% of women use private clinics or midwives for their family-planning-related medical care due to short distances and low transport costs, according to interviews conducted among 10,706 women, of whom 57% were in the country's lowest wealth quintile [18] .

Few studies have investigated “accessibility” per se (i.e., the ability to access available services). However, wait times were consistently found to be shorter in private sector than in public sector facilities [22] , [23] . One interview-based study in Ghana suggested that waiting times among public sector facilities could be longer for the same condition than private sector facilities by one or two hours [22] . Women living in rural Nigeria also reported preferring private obstetric services to public services because doctors were more frequently present at the time of patient presentation [23] .

Patients tended to report worse hospitality from providers at public than private facilities (13 studies) [24] – [36] . In Bangladesh, for example, public providers ranked lower than private providers on scale-based surveys in which patients assessed the diagnostic explanation given them, courtesy of staff, cleanliness of facilities, capacity building, and the availability of certain medical inputs [36] . A study in India found that patients were seen for longer durations, were more likely to have a physical exam during their visit, and were more likely to have their diagnosis explained to them by private sector physicians than public sector ones [33] . Analysis in several countries suggested that patients in private sector facilities reported preferring the facilities because of shorter waiting periods, longer or more flexible opening hours, and better availability of staff [34] .

Theme 2. Quality of Health Care

Nine retrospective chart reviews and survey-based studies found that diagnostic accuracy and adherence to medical management standards were worse among private than public sector care providers [37] – [45] . Most of these studies examined infectious disease management protocols, including for tuberculosis and malaria [46] . Private practitioners had significantly worse knowledge of correct diagnosis and treatment. Other disease categories showed similar patterns of lower quality in the private sector. In Nigeria, public providers were significantly more likely to use rapid malaria diagnostics and to use the recommended combination therapies than private providers [47] .

Similar poor adherence to guidelines in prescription practices, including subtherapeutic dosing, by private sector providers has been associated with a rise in drug-resistant malaria in Nigeria [47] . Parallel results were reported from Viet Nam [48] . In an analysis of outcome data from 24 countries, children with diarrhea were found to be less likely to receive appropriate oral rehydration salts and more likely to receive unnecessary antibiotics when seeing private providers than when seeing public providers [49] . However, a study of 119 private and ten public health clinics in Uganda found that both private and public providers prescribed antibiotics incorrectly (including not prescribing them when indicated), and in this study public providers were worse in adhering to national malaria treatment standards (14% versus 27%, p  = 0.002) [45] .

Poor adherence to guidelines in prescription practices, including prescribing subtherapeutic doses, failure to provide oral rehydration salts, and prescribing of unnecessary antibiotics were more likely to occur among private than public providers [47] – [49] , although there were exceptions [45] . Higher rates of potentially unnecessary procedures, particularly cesarean sections (C-sections), were also reported at private than at public settings [50] , [51] . One analysis of the Peruvian health system found significantly higher rates of C-sections after the privatization of delivery. The pre-reform rates in the private sector were already higher than the WHO recommended rate of 10%–15%; after reform, the rate exceeded 50%. The same has been found in South Africa, where 62% of women delivering in the private sector had C-sections, compared with 18% in the public sector [51] . Studies in Mexico suggested that fee-for-service payment structures (which are more heavily present in private than in public care delivery settings) incentivized increased C-sections [23] .

Two cross-sectional studies documented a lack of drug availability and service provision at public facilities. A semi-structured questionnaire distributed to 24 health secretariats and directors of 39 city hospitals and 26 referral and teaching hospitals revealed that 76% of state facilities and 67% of city facilities lacked assisted reproductive technologies that were widely available in private sector facilities (though the exact percentage among such private facilities was not evaluated) [52] . In Tanzania, a semi-structured questionnaire distributed to 80 randomly selected patients and 45 health facility personnel staff working in diabetic clinics found that private facilities tend to stock more types of oral hypoglycemic agents than public facilities [53] . However, studies did not make clear whether the additional types of drugs were related to better outcomes or were simply additional brands of equivalent medication on hand.

Some studies of quality of care were performed in the private sector without having a comparative public sector group. Two studies in South Africa found that the majority of private general practitioners were not aware of the recommended medications, doses, or durations for treatment of sexually transmitted infections [54] , [55] . Reviews in Nigeria and Laos reported similarly widespread use of ineffective therapies for malaria in the private sector [56] , [57] . Sexually transmitted disease management in private clinics and drugs shops in Uganda revealed that 93% of cases were not properly managed per national guidelines, and the cure rate was 47% [58] .

Dispensation of unnecessary medications and procedures was also reported to be higher among private sector providers according to four reports based on chart reviews. The most common incidents involved the unnecessary use of antibiotics for treatment of diarrheal diseases and non-complicated acute respiratory infections [32] , [49] . Reports from Africa and Laos suggest ineffective and sometimes harmful pharmaceuticals are being distributed in the private sector [56] , [57] .

Surveys of patients' perceptions of care quality were mixed. While two survey-based studies suggested that patients perceived higher quality among private practitioners, possibly due to frequent prescribing of medications and more time spent with patients [20] , [34] , three interview-based studies suggested that patients perceived public sector healthcare workers as more competent [32] , [59] , [60] .

Theme 3. Patient Outcomes

Public sector provision was associated with higher rates of treatment success for tuberculosis and HIV [61] – [64] as well as vaccination [65] , [66] . For example, in Pakistan, a matched cohort study in Karachi found that public sector tuberculosis care resulted in an 85% higher treatment success rate than private sector care [63] . In Thailand, patients seeking care in private institutions had significantly lower treatment success rates for tuberculosis, which was attributed to a three to five times greater likelihood of being prescribed non-WHO-recommended regimens than in the public sector [61] . In South Korea, tuberculosis treatment success rates were 51.8% in private clinics as opposed to 79.7% in public clinics, with only 26.2% of patients in private clinics receiving the recommended therapy, and over 40% receiving an inappropriately short duration of therapy [62] . Similarly higher rates of treatment failure were observed for private than public system patients on antiretroviral therapy for HIV in Botswana [64] . In India, an analysis of over 120,000 households, adjusted for demographic and socioeconomic factors, found that children receiving private health services were less likely to receive measles vaccinations [65] . Similar findings were reported from Cambodia [66] .

Studies comparing pre- and post-privatization outcomes tended to find worse health system performance associated with rapid and extensive healthcare privatization initiatives. In Colombia, following major privatization reforms in 1993, population vaccine coverage declined for several diseases in the country, and tuberculosis incidence rose significantly [67] . In Brazil, privatization of fertility control services led to increased abortions, sterilization, and improper use of oral contraceptives (obtained without medical consultation), ultimately linked to higher mortality rates among young women [68] . However, a slower pace of privatization of health care services did not appear to correlate with a substantial worsening in patient outcomes among Latin American countries [69] .

Theme 4. Accountability, Transparency, and Regulation

Data on this theme tended to be unavailable from the private sector. No papers were found to describe any systematic collection of outcome data from entirely private sector sources. One recent independent review of Ghana's private sector referred to the private sector as a “black box,” with a dearth of information on delivery practices and outcomes [22] . Tuberculosis and malaria case notification to the public health system was particularly poor among private sector providers as compared to public providers in a number of countries [28] , [48] , [70] . However, while national vital statistics databases collected from public sector clinics and hospitals were widely available, they varied considerably in quality according to external assessments [22] , [71] .

Public–private partnerships also lacked data. A systematic review of data from public–private partnerships (including arrangements among governments and private, for-profit contractors) found few reported data that were of sufficient quality to assess the impact of partnership services and programs [72] . Poor data availability was observed in another systematic collection from several countries' private–public partnerships for sexual and reproductive health services. Most data available showed that after brief training of health providers, provider responses to questionnaires improved in accuracy, but no assessments were made of health outcomes [71] . An exception was a partnership in India that demonstrated increased birth attendant coverage from 27% to 53% over 7 mo among a cohort of 97,000 women [73] .

Several reports observed significant public spending being used to regulate the private sector in order to improve patient care quality, particularly in African countries, and with limited effectiveness [22] , [74] – [76] . The effectiveness of these regulations of the private sector was found to vary, often depending on public monitoring and enforcement [17] , [34] , [77] . Regulations to reduce the sale of unnecessary breast milk substitutes by private drug shops in Laos had limited impact until government inspectors visited sites to ensure appropriate sales and provided sanctions for legal violations [17] . In Indonesia, Kenya, Pakistan, and Bihar, clinical education programs to improve distribution of oral rehydration salts and reduce inappropriate antibiotic prescribing were found to have a greater impact when patients also received education, and when community healthcare workers were involved in monitoring, than when education was given only to clinicians [17] . Reviews in Zimbabwe and Tanzania identified anti-competitive practices and sales of inappropriate drugs [75] ; attempted regulations in Zimbabwe were ineffective [76] . One review in Ghana indicated that the key public agency in charge of such regulation was unable to identify a large number of private providers in order to assess accreditation and quality: 2,612 of 11,430 drug shops were registered but had not received licenses [22] . A private–public partnership in South Africa to educate providers about national guidelines for sexually transmitted disease prevention and control had no effect on practice [77] . In Egypt a comparative assessment of clinical education programs found greater improvements in public sector practices than private sector practices [34] .

Theme 5. Fairness and Equity

Financial barriers to care, particularly user fees, were reported to be prevalent in both private and public systems. A World Bank study in Ghana concluded that there was no systematic evidence indicating whether user fees in the public sector were different than in the private sector [78] ; however, the data presented showed that out-of-pocket user fees for patients were highest for private not-for-profit, lowest for public, and intermediate for private self-financed providers [22] . Hence, the conclusions of the report appear to be disputed by the data within the report.

As noted in the preceding sections, private sector health services tend to cater more greatly to groups with higher income and fewer medical needs (an illustration of the “inverse care law”), resulting in disparities in coverage [35] , [79] – [85] , although findings varied in several cases [86] , [87] . Some studies suggested there was a systematic bias against indigent patients in terms of both quality and access. Exclusion of poor patients by the private sector was observed in South Africa [80] and Paraguay [81] . Poor patients were as likely as wealthier patients to seek care from private providers in Laos, but poorer patients received service from less qualified providers, with limited-quality services (no exam or advice, only medication dispensing) [35] . While most reports described income-based stratification in access, one report described stratification based on gender in addition to income. A nationally representative, cross-sectional, cluster-sample survey of 7,308 children in randomly selected rural and urban populations across Bangladesh observed that over 90% were taken to the private sector. However, when patients arrived at private clinics, children from higher income households and male children were significantly more often ( p <0.001) directed to a licensed provider and treated with oral rehydration solution or an antibiotic than female or poor children [85] .

Several studies suggested that the process of privatizing existing public services increased inequalities in the distribution of services. Analyses of the Tanzanian and Chilean health systems found that privatization led to many clinics being built in areas with less need, whereas prior to privatization government clinics had opened in underserved areas and made greater improvements in expanding population coverage of health services [82] – [84] . Privatization in China was statistically related to a rise in out-of-pocket expenditures, such that by 2001, half of Chinese surveyed reported that they had forgone health care in the previous year due to costs; out-of-pocket expenses accounted for 58% of healthcare spending in 2002 compared with 20% in 1978 when privatization began. The cost burdens of privatization related to an increase in disparities in healthcare coverage and infant mortality between urban and rural areas [79] . One survey-based study using Demographic Health Survey data from 34 sub-Saharan African countries found that privatization was associated with increased access, and reduced disparities in access between rich and poor [86] . A second analysis of the same dataset, however, found no change in inequality in use of modern contraceptives with the expansion of the private sector [87] .

Private contracting and social franchises showed potential for expanding private sector coverage to impoverished groups, although conclusions are tentative because comparisons to the public sector were unavailable. One World Bank study in Cambodia reported improvements in healthcare coverage in poor districts after contracting out services to private companies specifically to increase coverage. When contracts explicitly included targets for reaching the poor, contractors improved health services for the most marginalized groups, although comparison was not made to the results of a similar investment in public sector services [88] . Several related World Bank initiatives took the form of social franchises, in which private providers pay a fee and are provided training, managerial assistance, and certification in a provider network [20] , [89] , [90] . Several case studies of social franchises [20] , [89] , [90] found higher care utilization among the lower socioeconomic groups of private franchisers than of control private clinics for contraceptive use, HIV counseling, antenatal care, and vaccination [17] , [91] , [92] .

Theme 6. Efficiency

Several reports observed higher prescription drug costs in the private sector for equivalent clinical diagnoses [33] , [36] , [53] , [67] , [93] – [96] . In a survey study of prescription costs in India, costs were higher for every class of visit in the private sector [33] . Two-thirds of outpatients in the private sector, compared with one-third in the public sector, received an injection for similar presentations, but the study did not investigate what fraction was unnecessary [33] .

Both generic and brand-name drugs were found to be higher in price in the private sector [96] . Tanzanian private facilities typically used more brand-name oral hypoglycemic agents, but even generic medications were five times higher in price [53] . Similar findings were reported in India [96] . A study in Bangladesh found that private sector healthcare prices in the country—not just those associated with medications—have been growing far above the inflation rate [36] .

There is also evidence that the process of privatization is associated with increased drug costs [36] , [53] , [67] , [93] , [94] , [96] . A study of the Malaysian health system found that increasing privatization of health services was associated with increased medicine prices and decreased stability of prices [93] . Healthcare costs in Colombia rose significantly following privatization reform in 1993, and 52% of capitation fees were spent on administration [67] . Similar privatization in some parts of South Africa were associated with a 13% to 32% cost increase in overall health spending, without associated increases in coverage or indications [94] ; costs of prescriptions were significantly lower in the public sector, likely due to generic substitution, prepackaging of medications, and use of treatment protocols [95] .

Higher drug costs are in part associated with disease complications attributable to delayed diagnosis or incorrect disease management [97] , [98] . In Bolivia, seeking care in the private sector was associated with longer delays in tuberculosis diagnosis and greater costs [97] , [98] . It was estimated that in Mexico, Brazil, and South Africa, unnecessary C-sections increased delivery-related health costs in the private sector by at least 10-fold [23] . In Bangladesh, private contracting of health services appeared to increase costs related to complications and delays in service access [36] .

Several World Bank studies found significant fragmentation in purchasing and distribution across and within the public and private sectors, resulting in higher drug prices and redundant treatments that increase overall healthcare costs [22] , [99] . The absence of reliable distributors for pharmaceuticals in a study in Ghana led to several intermediary groups being used to distribute medications, increasing prices between 5% and 200% [22] . The large number of small-scale hospitals and clinics in some sub-Saharan African countries fragmented delivery, such that patient diagnoses and treatment histories were unavailable between institutions [22] , [99] , often significantly delaying care, and resulting in redundant tests and sometimes administration of incorrect medication to patients. Several private primary care providers reported difficulties referring their patients to public sector secondary care facilities, as public facilities did not accept the diagnoses made by the private providers and often required the patient to restart the consultation process [99] .

Competition between public and private delivery tended to decrease drug prices. One large multilevel analysis of the content and cost of 700 medication transactions observed in 14 private and public settings in Mali revealed that private providers were more likely to prescribe brand-name drugs, injectable drugs, and more antibiotics; however, the availability of drugs in the public sector decreased prices in the private sector [100] .

Contracting of public healthcare services to private providers has also been estimated by the World Bank to reduce costs of and waiting times for contracted services [36] , [101] , although the effects of contracting differ markedly by the type of healthcare service and across countries [17] , [102] . In Cambodia, contracted districts had costs of $22.7 per person per year versus $26.4 among non-contracted districts, although there were no tests of statistical significance [36] . One highly cited secondary analysis reported this outcome as a 17% savings resulting from contracting [101] . Peer-reviewed studies of contracting in Zimbabwe and South Africa found that costs were unchanged by contracting in South Africa but were lower after contracting in Zimbabwe [17] . One review of contracting experience in Madagascar and Senegal found that large expenditure from public sector ministries was necessary to manage and supervise private contracts, increasing overall costs in those two countries by 13% and 17%, respectively [102] .

Other Observed Factors

A few key findings reported in articles did not clearly fit into the WHO health system themes, mainly involving recent reports of complex “competitive dynamics” between private and public health sectors. First, a “crowding out” effect appeared to occur between private and public sector services for expanding delivery. This process involved the transfer of public funds and personnel to private sector development, followed by reductions in public sector service budgets and staff availability. In Ghana, new private services in urban middle- and upper-socioeconomic populations were found to reduce revenues for public sector hospitals that also provided care to poorer populations [22] . At times, however, the process was a passive privatization: public sector funds were increasingly allocated to private–public partnerships without accompanying shifts in demand, so that the public sector's effective budget per patient was reduced. This dynamic was observed in post-apartheid South Africa [103] , as well as in Uganda [104] and Brazil [105] . Public–private partnerships and private contractors were often involved in such scenarios, but did not typically disclose the data necessary to fully evaluate these arrangements.

Public and private sector interactions also had implications for delivery, staffing, and disease control. Interviews of Indian patients suggested that several private practitioners who work in both public and private sectors advised patients to visit their private clinics or requested further payments in order to continue providing care in the public clinic [106] . Doctors tended to migrate towards private sector and urban jobs, depriving the public sector and rural areas of physicians [107] . However, private hospital systems often subsidize or provide healthcare technologies to patients who cannot obtain these services from public hospitals. For example, in Botswana, private hospitals often receive cancer patients from public hospitals that are unable to provide radiation oncology services [78] . In some cases, however, the services in differing sectors undermined performance of one or both sectors. Several studies found that poor reporting of diseases in the private sector impeded public sector control of communicable diseases [28] , [48] , [70] .

Our systematic review of comparative analyses of public and private healthcare systems in low- and middle-income countries found strengths and limitations in both sectors for each of six main WHO health systems framework themes. Private sector healthcare systems tended to lack published data by which to evaluate their performance, had greater risks of low-quality care, and served higher socio-economic groups, whereas the public sector tended to be less responsive to patients and lacked availability of supplies. Contrary to prevailing assumptions, the private sector appeared to have lower efficiency than the public sector, resulting from higher drug costs, perverse incentives for unnecessary testing and treatment, greater risks of complications, and weak regulation. Both public and private sector systems had poor accountability and transparency. Within all WHO health system themes, study findings varied considerably across countries and by the methods employed.

The review has several limitations, which reflect the existing data and literature purporting to compare the healthcare performance of public and private sectors. First, existing studies have focused on isolated topics where data are more abundant, and as a result have overlooked important dimensions of health sector performance. To address this limitation, we drew on a broader range of data, including reports from non-governmental organizations and international agencies like the World Bank. This step was particularly important for acquiring data from the private sector, since such data are relatively unavailable in the peer-reviewed academic literature. Thus, some studies included were not peer-reviewed. Our review involved a detailed analysis of methodological criteria for these studies to ensure they met similar standards of data analysis and reporting as peer-reviewed research. Second, although it was not possible to perform a quantitative meta-analysis because of variations in coding and outcomes, we were able to identify unsubstantiated claims in several cases, which appeared more prominent among non-peer reviewed sources. For example, the World Bank has made strong claims that investing in public–private partnerships will improve efficiency and effectiveness in the health sector [108] , yet several of its publications revealed that these assertions were either unsupported by data or the data was not provided in sufficient detail to pass minimal inclusion criteria required for this review [20] , [78] . Efforts are needed to address potential conflicts of interest of such agencies and their implications for research and data reporting, particularly as their analyses are often very highly cited in the academic literature on health system assessment and performance.

Third, our reliance of the WHO health system themes enabled the analysis to address systematically and comprehensively the existing research on public and private sectors. However, a limitation of the thematic framework, for example, is that several elements of the patient experience in healthcare settings, such as waiting times, are not systematically cataloged in current assessments. This implies that future research in the area should include a focus on how experiential aspects of care are relevant to healthcare seeking and outcomes (such as the likelihood of follow-up among patients requiring return visits) for differently structured care environments. Fourth, the review identified mixed results in several cases and was unable to account for a range of potential modifying factors, partly as a limitation of the broad WHO health system components that do not incorporate contextual factors. For example, treatment of infectious diseases in public settings may be more efficient than in private settings because of higher volume, and greater use of systematized protocols due to that higher volume. Such differences limit the ability of existing work to compare fairly the public and private sector for differing disease categories and in differing social and economic contexts of healthcare delivery.

Although it was not the focus of our research, we observed that some of our findings in low- and middle-income countries mirrored existing evidence from high-income countries. For example, the lack of data from private sector groups was similar to the situation in the UK, where the privately run Independent Sector Treatment Centres was unable to provide healthcare performance data when required [109] . However, our evidence also indicates that contextual factors modify the relationships we have observed, so that it is not straightforward to transpose health system evidence from high-income countries to low- and middle-income countries. Importantly, we observed that regulatory conditions interact with the effectiveness of public and private sector provision, but in low- and middle-income countries regulatory capacity is much weaker. As one example, the reviewed data suggest that systems that incentivize more procedures (rather than better outcomes) tend to lead to inefficiencies and poorer health outcomes. One extensively studied alternative system in high-income countries is pay-for-performance remuneration systems. It remains unclear what effects such programs may have in low- and middle-income countries as compared to high-income countries.

Our study has important implications for future research and policy. Future research is needed to address several important methodological limitations of existing studies. Many analyses were excluded from the review because they lacked a systematic approach to cataloging health system quality. Ideally, analyses should be comparative and should include a “counterfactual” in order to make causal claims about the effects of the particular benefits of providing services in one sector or the other. For example, social franchising to engage private providers in an organized regulatory system, which has been extensively piloted, has yet to be analyzed over the long term using outcome data and a comparison with commensurate investment in public sector development [88] . Studies also need to specify carefully the definition of the private and public sectors. When the private sector included unlicensed physicians, it was found to provide the majority of coverage for low-income groups, but when only licensed providers were included, the public sector was found to be the main source of healthcare provision in low- and middle-income countries. While some commentators report a higher number of absolute healthcare workers in the private sector, and a higher number of visits among the population to the private sector, these observation may be artifacts of improperly coding a large portion of private “providers” who are not actually qualified healthcare personnel, but rather drug store salespeople [1] , [5] . Most studies fail to capture the full scope of effects of reforms on the healthcare system, focusing on an isolated health system component. A reform may enhance public sector performance but compromise the market in the private sector, or vice versa. Standards may need to be developed for health system research for identifying what is “safe” and “effective” overall for patients across socioeconomic strata, just as we do for pharmaceutical safety and efficacy.

Some authors have highlighted the lack of regulatory infrastructure available in low- and middle-income countries to monitor the performance of private healthcare contractors [110] . Despite the lack of data about private sector performance, recent initiatives by the World Bank's International Finance Committee are underwriting the expansion of private sector services among low- and middle-income countries. For example, in sub-Saharan Africa, the International Finance Committee has created a private equity fund to make 30 long-term investments in private health companies. These conflicts of interest pose a potential threat to the validity of World Bank–sponsored studies and raise the need for independent scrutiny.

Our review indicates that current data do not support claims that the private sector has been more efficient, accountable, or medically effective than the public sector [8] . The review also identifies several areas of focus for quality improvement. In the private sector, benefits may accrue from enhancing medical knowledge for appropriate diagnosis and disease management, drawing on specific quality improvement programs for continuing medical education that may serve as models [17] . It is also important to address conflicts of interest from physician-induced demand, particularly when prescribers are also drug store owners. Regulation and consumer education have been more successful than a reliance on clinical education alone in Pakistan and Bihar [17] . In the public sector, quality improvement may need to address incentives to perform at high standards among providers who may not feel threatened by a lack of business in the manner that private practitioners do. One proposed approach is to link provider compensation with results from patient outcomes, weighted by baseline disease risk in the patient population [111] . More generally, policy research needs to determine how targeted interventions might address these core weaknesses among both private and public delivery environments, including the lack of disclosure of outcome and performance data; as a measure of accountability, public transparency can be considered a vital sign of system performance (particularly for those systems receiving public subsidies; [112] ). While there is no clear definition of a “basic minimum dataset” for countries to capture health sector performance, we did notice several common themes in our data review. In many of the countries studied, surveillance of disease treatment outcomes among adults, and particularly noncommunicable disease, was found to be limited. Furthermore, we found further data gaps in health system performance around the issues of waiting times, financing changes (e.g., to further characterize the “competitive dynamics” we described), and outcomes of quality improvement efforts within each sector.

A critical challenge in years to come is how to address competitive dynamics between private and public realms, so that public sector facilities are not stripped of resources that are given to the private sector as subsidies, and so that the ability of public clinics and hospitals to retain skilled healthcare workers is not compromised, especially as both types of systems attempt to coexist in the healthcare delivery environment of low- and middle-income countries. These findings are consistent with earlier findings of an “infrastructure inequality trap” in some countries [103] , in which government funding is increasingly attracted towards private hospitals and away from the public sector hospitals. This occurs when private patients can afford to pay for greater infrastructure at private hospitals. Those hospitals then report greater “absorptive capacity” for future funds, and higher numbers of healthcare personnel, thereby attracting more funding from government institutions, shifting budgets away from public sector facilities that struggle to maintain human and physical infrastructure. Furthermore, we found evidence that many public–private initiatives involve public sector funding being dedicated to monitoring and preventing corruption in the private sector.

Overall, the data describing the performance of public and private systems remains highly limited and poor in quality, suggesting that further investigations should more systematically make data available to track the performance of both public and private care systems before further judgments are made concerning their relative merits and risks.

Supporting Information

Search strategy.

https://doi.org/10.1371/journal.pmed.1001244.s001

PRISMA checklist.

https://doi.org/10.1371/journal.pmed.1001244.s002

Author Contributions

Conceived and designed the experiments: SB JA DS RP. Performed the experiments: SB JA. Analyzed the data: SB JA. Wrote the first draft of the manuscript: SB JA DS. Contributed to the writing of the manuscript: SB JA DS SK RP. ICMJE criteria for authorship read and met: SB JA DS SK RP. Agree with manuscript results and conclusions: SB JA DS SK RP.

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• Research article
• Open access
• Published: 27 February 2018

Comparing public and private providers: a scoping review of hospital services in Europe

• Liina-Kaisa Tynkkynen 1 &
• Karsten Vrangbæk 2  

BMC Health Services Research volume  18 , Article number:  141 ( 2018 ) Cite this article

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What is common to many healthcare systems is a discussion about the optimal balance between public and private provision. This paper provides a scoping review of research comparing the performance of public and private hospitals in Europe. The purpose is to summarize and compare research findings and to generate questions for further studies.

The review was based on a methodological approach inspired by the British EPPI-Centre’s methodology. This review was broader than review methodologies used by Cochrane and Campbell and included a wider range of methodological designs. The literature search was performed using PubMed, EconLit and Web of Science databases. The search was limited to papers published from 2006 to 2016. The initial searches resulted in 480 studies. The final sample was 24 papers. Of those, 17 discussed economic effects, and seven studies addressed quality.

Our review of the 17 studies representing more than 5500 hospitals across Europe showed that public hospitals are most frequently reported as having the best economic performance compared to private not-for-profit (PNFP) and private for-profit (PFP) hospitals. PNFP hospitals are second, while PFP hospitals are least frequently reported as superior. However, a sizeable number of studies did not find significant differences. In terms of quality, the results are mixed, and it is not possible to draw clear conclusions about the superiority of an ownership type. A few studies analyzed patient selection. They indicated that public hospitals tend to treat patients who are slightly older and have lower socioeconomic status, riskier lifestyles and higher levels of co-morbidity and complications than patients treated in private hospitals.

Conclusions

The paper points to shortcomings in the available studies and argues that future studies are needed to investigate the relationship between contextual circumstances and performance. A big weakness in many studies addressing economic effects is the failure to control for quality and other operational dimensions, which may have influenced the results. This weakness should also be addressed in future comparative studies.

Peer Review reports

Public funding, as well as public provision of healthcare services, has been a key feature of many modern welfare states. However, since the 1980s the realms of the public and private sectors have been redefined in many countries [ 43 ]. At the same time, systems financed through social or private insurance have developed new ways of organizing their relationships with providers. What is common to all healthcare systems is a discussion about the optimal balance between public and private provision.

In a seminal paper from 1963, Kenneth Arrow demonstrated that health care has a number of characteristics that violate the principles of a perfect market [ 3 ]. Healthcare consumers do not have sufficient information to know when and to what extent health care is needed or to compare alternatives. Externalities are not incorporated in decision making, and patients risk catastrophic losses in the event of serious illness. Attempts to solve this problem through private insurance carry other risks in terms of adverse selection and moral hazards. As a consequence, all modern healthcare systems have some degree of public involvement in the regulation, financing or provision of services. The implication is that health care is delivered in highly regulated markets with different combinations of public and private actors [ 7 ]. This leads us to ask whether there is evidence that private delivery organizations perform better than public delivery organizations in regulated health care markets.

We investigated this question by conducting a scoping review of the available evidence from recent studies within the European region. Although this region includes different types of healthcare systems, all countries rely considerably on public or not-for-profit providers in addition to some degree of private for-profit delivery. Focusing on the European region allowed us to include systems that are based on similar values about solidarity, while excluding studies from countries with radically different underlying values, such as the United States (US) and Singapore. At the same time, by including the entire region, we can expand on the degree of diversity and volume compared to previous studies, such as Tiemann et al. [ 50 ].

Our method was a scoping review which aimed to summarize and compare previous studies presenting evidence on differences in performance between public and private hospitals in European healthcare systems. Scoping reviews aim to “map rapidly the key concepts underpinning a research area and the main sources and types of evidence available and can be undertaken as stand-alone projects in their own right” [ 2 ]. The specific purpose of this review was to summarize and compare research findings, to relate the findings to previous reviews and to generate questions for further studies and systematic reviews.

Theoretical perspectives on public–private comparisons

Theoretical claims for positive effects of private ownership typically stem from public choice and property rights theories, which revolve around a competition and a public management/ownership argument, respectively [ 1 , 13 , 21 ]. The competition argument states that although healthcare markets may be imperfect, competition in itself can have beneficial effects. Private providers are forced by competitive pressure to optimize efficiency, while political and administrative pressures are more important for public providers. The lack of competitive pressures means that public managers are unable to measure the efficiency of their organizations against a commercial bottom line. Decisions on resource allocation and survival of the organization are left to public decision makers who cannot rely on market prices to generate an equilibrium between demand and supply.

The public management/ownership argument states that public sector organizations lack incentives to perform efficiently, these organizations often have broad and conflicting objectives, and they have no bankruptcy constraint. That is, they can continue to perform at sub-optimal levels without the risk of going out of business [ 1 ]. Furthermore, public organizations are not accountable to shareholders and owners and therefore, potentially have less external pressure to focus on innovation and technological development. Finally, it has been argued that a major difference between public and private hospitals is that public hospitals tend to operate in settings with “soft budget constraints” [ 22 , 40 ]. Some countries have tried to overcome this difference through various types of purchaser–provider splits [ 7 ] and legislation regarding hard budget constraints such as the Danish “Budget Law.”

Several theoretical contributions have nuanced and broadened the expectations from public choice and property rights theory [ 10 , 53 ]. Transaction cost economics emphasizes the importance of asset specificity and the measurability of the services that are provided in the market [ 15 , 54 ]. Rather than approaching public services as something that would, by definition, be more effectively produced in a private market, transaction cost economics hypothesizes that different service characteristics create more or less favorable conditions for in-house production and contracting [ 29 ]. Economic benefits from contracting are more likely to be realized if the quantity and quality of the services can be unambiguously described and measured. Otherwise, the costs of preparing tenders, evaluating bids, signing contracts and monitoring (and possibly sanctioning) service delivery are likely to be high. The largest economic effects, thus, are expected in technical services characterized by low asset specificity and high measurability, whereas smaller or even negative economic effects would be expected in complex services with high asset specificity and low measurability. For hospitals, this would lead us to expect that standardized procedures, for example, within some surgical areas and technical support functions are more likely to provide privatization benefits than complex services within the field of psychiatry or geriatrics, for instance. Hospitals are complex organizations, which typically include high- and low-specificity services. According to asset specificity theory, this leads to additional uncertainty about the benefits of privatization compared to the competition and ownership argument.

Industrial organization theory stresses a number of factors that make public markets distinct from traditional private markets and thus, create less optimal conditions for contracting out than expected by public choice theory [ 10 ]. According to this perspective, many public services are characterized by natural monopolies and high entrance costs, which limit competition and potentially make highly regulated markets with public providers less efficient than private markets [ 26 ]. Principal-agent theory further emphasizes the problem of information particularly in markets for welfare services, such as health, social and child care, where those buying the service have limited insight into the actual delivery practice of the agents. The presence of information asymmetries can lead to goal displacement and unwanted practices, such as “cream-skimming” (selection of the easiest tasks) and “parking” of the least profitable clients. This can endanger the system-level benefits assumed in perfect market conditions.

Decreasing marginal effects from contracting out suggests that economic effects tend to decrease over time [ 8 , 34 , 35 ]. There are two theoretical claims behind this argument. First, it is likely that rational purchasing organizations begin with contracting out those services and tasks where the largest gains are expected. Once the organizations have harvested the low hanging fruits, we can expect decreasing benefits from additional contracting out [ 9 , 34 ]. Second, involvement of private providers creates competitive pressure on public in-house production units, which may lead to more effective public production [ 5 ]. The market mechanism and exposure to competition, according to this argument, increase the efficiency of not only the contracted services but also the internally produced services [ 9 ]. Once the public providers have adjusted their operational practices, there will be few or no additional gains from switching to private providers.

The focus of this paper was to provide an empirical overview of efficiency results as reported in the empirical studies we identified in our database searches. The studies employed slightly different definitions and techniques (see Table  3 ), but data envelopment analysis (DEA) and stochastic frontiers analysis (SFA) techniques dominate. Technical and allocative efficiency comprises “overall efficiency” [ 33 ]. Technical efficiency is producing the maximum amount of output from a given amount of input or alternatively, producing a given output with minimum input quantities, such that when an organization is technically efficient, it operates on its production frontier. Allocative efficiency occurs when the input mix is that which minimizes cost, given input prices or alternatively, when the output mix is that which maximizes revenue, given output prices.

In addition to efficiency differences, we reviewed evidence of potential quality differences and operational differences between public and privately owned organizations. Operational differences include factors such as patient selection, staff composition and procedures that may include thresholds for admissions. In terms of quality, the measurements used were diverse which made it difficult to draw clear conclusions across the studies. Still, quality and operational parameters are important as they relate to other policy objectives than efficiency. However, very few studies embarked on multidimensional assessments, and narrow efficiency measures were, by far, the most commonly reported dimension.

Setting the stage: The results from previous review studies

We start by summarizing state-of-the-art as presented in previous international review papers that examined differences in economic and/or quality performance between private and public hospital organizations. The review studies were not included in the core sample, as we focused on primary studies published from 2006 to 2016 within the European region. Herrera et al. [ 32 ] provided an overview of systematic reviews of the performance of private for-profit (PFP), private not-for-profit (PNFP) and public healthcare providers. The authors reviewed 5918 references to identify systematic reviews and ended up with nine relevant studies of sufficiently high quality. According to the nine systematic reviews, ownership appears to have an effect on health- and healthcare-related outcomes. In the comparison of PFP and PNFP providers, significant differences in terms of patient mortality and payments to facilities were found; both were higher in PFP facilities. In terms of quality and economic indicators, such as efficiency, there were no significant results. When PNFP and public providers were compared, as well as PFP and public providers, no clear differences were found. The overall conclusion from the study was that PFP providers seem to have poorer results than their PNFP counterparts, but there are still important evidence gaps in the literature that need to be covered.

Currie et al. [ 18 ] reviewed 34 studies. Most of these studies found no difference between PFP and PNFP full-service hospitals in terms of relative costs, quality of care or efficiency. Shen et al. [ 46 ] employed a quantitative method when reviewing 40 studies to identify the factors that explain the different findings for cost, revenue, profit margin and efficiency in the empirical literature. The authors found that variations in the magnitudes of ownership effects could be explained by the research focus and methodology of the individual studies. Studies using empirical methods that controlled for a few confounding factors tended to find larger differences between PFP and PNFP hospitals than studies that controlled for a wider range of confounding factors. Functional form and sample size also matter. Failure to apply log transformation to highly skewed expenditure data yielded misleadingly large estimated differences between PFP hospitals and PNFP hospitals. Studies with fewer than 200 observations also produced larger point estimates and wider confidence intervals. In a follow-up study conducted in 2008 by Egglestone et al., the authors found that pooled estimates of ownership effects are sensitive to the subset of studies included and the extent of overlap among hospitals analyzed in the underlying studies [ 23 ]. Ownership appears to be systematically related to differences in quality among hospitals in several contexts. Whether studies found PFP and public hospitals have higher mortality rates or rates of adverse events than their PNFP counterparts depended on the data sources, time period and region covered.

Tiemann et al. [ 50 ] investigated hospital ownership and efficiency in a review of studies that focused on Germany. The authors concluded that in line with the evidence found in studies from other countries, especially the US, the evidence from Germany suggests that private ownership (i.e., PFP and PNFP) is not necessarily associated with higher efficiency compared to public ownership. Irvin’s [ 36 ] review of studies of U.S. healthcare organizations showed that there is a quality gap between for-profit and nonprofit firms in some healthcare sectors (long-term care and mental health), depending on the prevailing type of financial payment for health care.

Hollingsworth [ 33 ] reviewed 317 studies published until 2006. He concluded cautiously “that public provision may be potentially more efficient than private, in certain settings.”

The overall impression from previous review studies is mixed. Some studies found that public hospitals are more efficient than private, while others found no significant difference. In general, it appears that PNFP hospitals tend to be closer to public hospitals in outperforming PFP hospitals in terms of quality and efficiency.

These diverging and somewhat surprising results inspired two groups of scholars [ 23 , 46 ]) to investigate the methodological basis for the results. The authors emphasized that case selection, methodological approach, time period and region are important underlying factors. A general observation across the studies was that the true effect of ownership seems to depend on the institutional context and that there are significant differences across regions and markets and over time.

The aim of this paper was to add an update to the results described above. We do that by providing a scoping review of peer-reviewed primary studies on public–private comparisons in specialized health care. We focused on studies that were conducted over the past decade within the European region.

Scoping reviews aim to “map rapidly the key concepts underpinning a research area and the main sources and types of evidence available and can be undertaken as stand-alone projects in their own right [ 2 ]. These reviews can typically have any of four motivations: (1) to “examine the extent, range and nature of research activity,” that is, a mapping to elucidate the extent and range of research in the area; (2) “to determine the value of undertaking a full systematic review”; (3) to “summarize and disseminate research findings”, operating in the direction of a systematic review, describing findings in greater detail and acting to summarize and disseminate findings to key stakeholder audiences with the intention of informing those stakeholders and eliminating or reducing the need to undertake a more in-depth review; and (4) to “identify research gaps in the existing literature.” In our case, we aimed to summarize research findings and generate questions for further studies and systematic reviews.

The review was based on a methodical approach inspired by the British EPPI-Centre’s methodology. This review was broader than review methodologies used within the Cochrane and Campbell collaborations, which emphasized randomized controlled trials (RCTs) as the gold standard [ 38 ]. The present review also included a broader range of methodological designs and quantitative and qualitative studies Petersen et al. [ 42 ].

The literature search was conducted using PubMed, EconLit and Web of Science databases. The search was limited to papers published from 2006 to 2016. The limitation to the most recent decade was to avoid too much overlap with previous reviews while including the most recent studies. The inclusion criteria were papers written in English that dealt with the European region. The search strategies for the databases are presented in Table  1 .

The assessment and compilation of the final sample of relevant studies included three phases. Phase 1 included a search for relevant literature. The initial searches resulted in 480 studies: 354 from PubMed, 93 from EconLit and 53 from Web of Science of which some were duplicates. In phase 2, the abstracts were sorted using the categories not relevant, perhaps relevant and relevant. The not relevant category included papers that were not based in Europe or in which public–private comparisons were not found. The perhaps relevant category included papers whose suitability could not be judged solely on the abstract. Phase 3 included the final assessment of the relevance of the papers. For the relevant or perhaps relevant abstracts, the full papers were further examined, which resulted in grouping the studies that were finally included in the study and studies that were found not relevant after the full paper was read. In this phase, the not relevant papers were mostly theoretical papers, papers in which there were, eventually, no empirical public–private comparisons or very vague descriptions of the comparative material. At this stage of the process, we also excluded studies that addressed outsourcing, privatization and corporatization of hospitals with a focus on the dynamic process of transfer from one ownership type to another.

The final sample of studies that fulfilled the inclusion criteria was 24 papers. All of the papers were published in peer-reviewed journals, and we did not conduct further quality evaluations as the papers had undergone a peer-review process (Fig.  1 ).

Overview of the review procedure

The studies represented 10 countries (Table  2 ). Since 2006, we observed a slight increase in the number of papers published on the subject (Fig.  2 ). This increase confirms the trend observed by Hollingsworth although he reported a “dramatic” increase over the past decades [ 33 ].

Number of studies by year

Most often, the studies in this sample involved comparisons of two groups: public and private hospitals ( n  = 13). However, the definitions of public and private varied. Eleven studies made clear distinctions between public, PFP and PNFP hospitals. Economic effects were explored in 17 studies and quality in seven studies (in three studies, it was used as a control for economic effects). Patient selection was mentioned in 15 studies but discussed explicitly in only seven studies.

The majority of the studies ( n  = 17) found in the database searches addressed the economic performance of public and private specialized care organizations. Seven studies addressed quality.

In terms of economic performance, 15 studies compared public (PUB) hospitals to PFP hospitals. Some studies reported technical, cost and profit efficiency (see Table 3 ). About half of these studies reported that public hospitals are superior to PFP hospitals in terms of efficiency. Most of the other studies found insignificant differences. Only one study reported that PFP hospitals have better profit efficiency. Eight studies compared the performance of PFP and PNFP hospitals. The majority of these studies found that PNFP hospitals are superior in terms of technical, cost and profit efficiency. Only one study pointed to responsiveness as a performance measure where PFP hospitals are better than PNFP hospitals. Finally, we found 11 studies compared PUB and PNFP hospitals. Most of these studies reported insignificant differences. In the remaining studies, we found slightly more studies presented PUB hospitals as superior to PNFP hospitals.

Overall, it seems that in terms of economic performance the public hospitals in the 17 studies representing more than 5500 hospitals across Europe perform better than PNFP hospitals, which, in turn, perform better than PFP hospitals. However, a sizeable number of studies did not find significant differences. In terms of quality, the results were mixed, and it is not possible to draw clear conclusions about the superiority of an ownership type.

The following sections provide details about the studies and their results.

Economic performance: Technical, cost and profit efficiency

Berry et al. [ 11 ] looked at operating room productivity in independent anesthesiology departments within German hospitals by using survey data from 87 hospitals. The authors hypothesized that operating room productivity is higher for hospitals run by private corporations compared to those run by the public sector. In the analysis, they found some confirmation of this idea but presented no significant results. The overall conclusion was that hospital size is the single largest predictor of productivity. However, the authors also suggested that micro-level management processes matter.

Kontodimopoulos et al. [ 39 ] found that after controlling for contextual characteristics technical efficiency was not significantly different between public and private dialysis facilities in Greece. The authors concluded that the context rather than ownership influences the performance of service providers. Barbetta et al. [ 6 ] stressed the importance of contextual factors and reimbursement practices in a study in which they looked at the technical efficiency of public and PNFP hospitals in Italy. The authors suggested that the differences in economic performance are related to institutional settings in which providers operate rather than to the ownership per se.

Czypionka et al. [ 19 ] looked at the impact of ownership on efficiency in Austria. Contrary to several previous studies, the authors found that there is a significant association between efficiency and ownership when comparing public and PNFP hospitals. The latter outperform public hospitals in technical efficiency due to different financial incentives.

Herr [ 30 ] found that in Germany PFP and PNFP hospitals are, on average, less cost-efficient and less technically efficient than publicly owned hospitals. This result can be partly explained by the importance of length of stay, which was, at the time, highest in PFP hospitals. Similar results were found in the study by Tiemann and Schreyögg [ 51 ] who evaluated the efficiency of public, PFP and PNFP hospitals in Germany. The results showed that public hospitals perform significantly better than PFP and PNFP hospitals. However, Herr et al. [ 31 ] found no significant differences in cost and profit efficiency between public and PFP hospitals in Germany.

Daidone and D’Amico [ 20 ] looked at how the production structure and level of specialization of a hospital affect its technical efficiency in Italy. They found that PFP hospitals use resources less efficiently compared to public and PNFP hospitals. PFP hospitals work in slightly over-staffed conditions for medical staff while public and especially PNFP hospitals are over-staffed by technical and administrative staff. Caballer-Tarazona et al. [ 17 ] compared public hospitals and public–private partnership (PPP) model hospitals in the Valencia region, but they were not able to determine the effect of ownership on efficiency due to the small sample size.

Comparisons of costs and other economic outcomes

Two studies—both from Switzerland employing similar data—found that hospital ownership does not affect hospital costs [ 24 , 25 ]. Bonastre et al. [ 14 ] analyzed the use of expensive anticancer drugs in public and private hospitals. The authors found that there were significant differences in terms of capacity, volume of activity and case mix between private and public hospitals, but after adjusting for the case mix, there were no differences in the use of expensive drugs between private and public hospitals.

Kondilis et al. [ 37 ] compared the operation and performance of PFP and public hospitals in Greece, focusing on differences in nurse staffing rates, average lengths of stay and Social Health Insurance (SHI) payments (including per diem fees, plus additional fee-for-service payments for services provided during hospitalization) for hospital care per patient discharged. The authors found that there were differences between PFP and public providers operating within the mixed healthcare system. PFP hospitals had lower bed capacity, lower occupancy rates and lower nurse (total and high qualified) staffing rates compared to public hospitals. PFP hospitals are also associated with higher unweighted length of stay and higher payments per discharge, at least in the case of discharged patients are beneficiaries of the SHI funds.

Siciliani et al. [ 45 ], in turn, studied patients’ length of stay in public hospitals, specialized public treatment centers and private treatment centers that provide elective hip replacement in England. The authors found that public and private specialized treatment centers, on average, had 18% and 40% shorter lengths of stay, respectively, compared with public hospitals. The result remained the same after controlling for age, gender, diagnosis and market characteristics. They did not find that patient selection explains differences in the length of stay in different hospital settings.

Augurzky et al. [ 4 ] studied the differences between public, PFP and PNFP ownership types in German hospitals based on their probability of default (PD). According to the results, public hospitals tend to exhibit a PD that is significantly above average. This association indicates that public ownership may conflict with financial sustainability. The authors explained it by stating that it is possible that public guarantees are the key driver to explain the differences. Public backing opens the window that ceteris paribus public hospitals may have higher PDs without being necessarily closer to insolvency than private hospitals.

Schwierz [ 49 ] studied ownership-specific differences in the responsiveness of changes in demand for hospital services in Germany from 1996 to 2006. He found that in the speed of adaptation to increasing demand PFP ownership is superior to public and PNFP ownership. PFP providers also tend to expand in markets with decreasing demand. This result can be partly explained by the results found by Augurzky et al. [ 4 ] for higher probability of default. That is, the defaults of public hospitals nurture the process of privatization of public sector actors in a situation in which the public sector needs to reform their facilities and work practices while at the same time containing costs.

Solborg Bjerrum et al. [ 47 , 48 ] conducted two studies in Denmark that addressed the quality of elective surgeries in public and private hospitals. The 2015 study concerned patients who had cataract surgery in either public or private eye clinics or hospitals from 2002 to 2010. The results showed that patients who have cataract surgery in public hospitals have an overall statistically significant 62% higher mortality rate compared to patients who have cataract surgery in private hospitals or clinics. The potential explanation may be in the patient selection since the results indicate that patients who have cataract surgery in public hospitals are less healthy than patients who have cataract surgery in private hospitals or clinics (see more in the next section).

Another study by Solborg Bjerrum et al. [ 48 ] in Denmark addressed the risk of postoperative endophthalmitis (PE) in public and private eye clinics or hospitals from 2004 to 2012. The results showed that PE risk is 0.36 per 1000 operations in public hospitals and 0.73 per 1000 operations in private hospitals. Further analysis of the clinics revealed that there is homogeneity in the PE risk among the eye departments in public hospitals ( p  = 0.6) but heterogeneity in the PE risk among the private hospitals or eye clinics ( p  = 0.0001). Six private hospitals or clinics (out of 28) had a statistically significantly higher PE risk compared with the eye departments in public hospitals.

The third study from Denmark concerned how ownership affects professional behavior, treatment quality and patient satisfaction. In a mixed-methods study, Bøgh Andersen and Jakobsen [ 16 ] found that private clinics optimize non-clinical factors, such as wait times, more than public providers. The clinical procedures in the clinics, however, were very similar, and private clinics did not achieve better clinical results. Patient satisfaction was still higher in private clinics. Thus, the general conclusion of the study was that although ownership seems to influence certain aspects of care, the high level of professionalization neutralizes the effect which can be seen in the clinical results.

Pérotin et al. [ 41 ] studied whether hospital ownership affects the level of quality reported by patients in areas other than clinical quality (information and interpersonal care, respect for privacy, dignity and hospitality and delays) in England. The authors found that results vary across specialties and patient groups. The sum of all ownership effects was not statistically significant which led the authors to conclude that hospital ownership does not seem to determine the level of quality of the average patient’s reported experience. The authors also stated that the differences in the quality levels between the private and public sectors are mostly attributable to patient characteristics, patient selection into public or private hospitals and unobserved and specific hospital characteristics, rather than to hospital ownership.

Sanjay et al. [ 44 ] studied patient selection criteria, anesthetic preferences and outcomes of elective inguinal hernia repair in public and private sectors in England. The authors found that the mean wait time for patients undergoing hernia repair is 129 days in the public sector (range 16–379 days) and 15 days (range 8–61 days; p  = 0.001) in the private sector. Caballer-Tarazona et al. [ 17 ] found some evidence that private ownership (PPP) seems to have a positive effect on some quality dimensions, such as access to care. In readmissions, Berta et al. [ 12 ] found that PNFP hospitals show the highest frequency of readmissions compared to public and PFP hospitals.

Sanjay et al.’s [ 44 ] results also showed differences in treatment practices: Anesthesia appears to be the preferred option in the private sector (52%) and local anesthesia in the public sector (66%; ( p  = 0.0002). After a follow-up at 6 months, there was a postal questionnaire survey regarding chronic groin pain and satisfaction rates. No statistically significant difference was noted in the incidence of post-operative complications, recurrence and groin pain and satisfaction rate between the patients treated in public or private facilities. Grilli et al. [ 27 ], in turn, found that ownership status and payment structure have a strong impact on the adoption and use of a new technology, drug-eluting stents. Public hospitals use drug-eluting stents more selectively than private hospitals targeting the new device at patients who have a high risk for adverse effects.

Grotle et al. [ 28 ] studied sociodemographic, lifestyle and clinical characteristics in patients who were operated for lumbar disc herniation in public and private clinics in Norway. The authors evaluated whether selection for surgery and surgical treatment differed between public and private clinics. The main results were that more patients operated in private clinics are sent home the same day of surgery, and a larger proportion of the patients receive prophylactic antibiotic treatment. There were also more complications in public clients compared to the private clinics. However, the patients treated in the private sector were different compared to the patients treated in the public clinics. This, again, may be the explanation behind the results. We turn to the discussion on patient selection in the following section.

Operational differences

Patient selection.

In terms of performance, it is relevant to assess whether hospitals engage in patient selection to reduce their risks and costs. In an unregulated competitive market, this may be a rational reaction, but it also creates a problematic bias in the results if the patient base varies significantly between public and private hospitals in individual studies.

Solborg Bjerrum et al. [ 47 ] found that patients treated in public and private settings are significantly different. The mean age at first eye cataract surgery decreased statistically significantly during the study period but significantly more so in patients operated in private hospitals or clinics than patients operated in public hospitals. Furthermore, the results of the mortality analyses indicated that patients who have cataract surgery in public hospitals are not as healthy as patients who have cataract surgery in private hospitals or clinics. Bøgh Andersen and Jakobsen [ 16 ] found that private hip replacement clinics have fewer complications than patients than public clinics.

Berta et al. [ 12 ] showed that private hospitals are involved in cream skimming at a much higher rate than public and not-for-profit hospitals. Sanjay et al. [ 44 ], in turn, found in England that patients undergoing surgery in the private sector are slightly younger compared to those treated in the public sector, that the number of patients with the American Society of Anesthesiologists (ASA) grading system grades III and IV is higher in the public sector (28.6%), and that there are a higher number of ASA I and II (83%) patients in the private sector.

In a study conducted in Italy, Grilli et al. [ 27 ] showed that patients in public hospitals are older and more likely to undergo percutaneous coronary intervention (PCI) for indications such as acute myocardial infraction and unstable angina than patients in private hospitals. In addition, patients with stable angina are more prevalent in private hospitals than in public hospitals. Furthermore, patients with multivessel disease who undergo PCI with stenting are significantly more prevalent in public centers with and without open-heart surgical facilities than in private centers. Finally, the proportion of patients with high-risk lesions is higher in public hospitals than in private hospitals.

Grotle et al. [ 28 ] found that patients who have lumbar disc herniation surgery in a private clinic are somewhat younger (1.3 years), are more likely to be male, have higher education and are less likely to be unemployed. The proportion of patients who were on sick leave was somewhat higher in private clinics than in the public sector. However, the duration of sick leave before surgery was significantly higher. In the public sector, the mean duration was 24 weeks (SD = 36.4) whereas in the private sector it was around 15 weeks (SD = 20.7). Grotle and colleagues also found that the proportions of disability and retired pensioners are more than double in the public sector compared to that for private clinics. There were also higher proportions of patients who smoked and were obese (BMI > 30) in the public health services. Furthermore, public sector patients used more pain relief, had a longer duration of pain in the back and leg, and had more comorbidities, such as heart disease, hip osteoarthritis, depression and chronic lung diseases. There was also a higher ASA grade among patients operated in public hospitals.

In sum, the limited number of studies analyzing patient selection indicated that public hospitals tend to treat patients who are older and have lower socioeconomic status, riskier lifestyles and higher levels of co-morbidity and complications than patients treated in private hospitals.

Other operational dimensions

Other operational dimensions, such as differences in staff composition, skill level and working conditions, are very likely, but were not reported systematically in the studies included in this study sample. Berta et al. [ 12 ] analyzed effects of distortions (i.e., upcoding, cream skimming and readmissions) induced by the prospective payment system on hospitals’ technical efficiency in Italy. They found that PNFP and public hospitals have the same efficiency levels, while PFP hospitals have the lowest technical efficiency. This could be at least partially explained by the finding that private hospitals are more engaged with cream skimming which, in turn, was found to have a negative impact on hospitals’ technical efficiency. The role of the payment structure was also taken up by Augurzky et al. [ 4 ]. They found that public hospitals tend to exhibit PD at much higher levels than the hospitals in the sample did, on average. This could be explained by the public backing which affects hospital incentives to perform in a financially sustainable way (compare, e.g., [ 40 ]). Differences in financial incentives to hospitals of different ownership status were also brought up by Czypionka et al. [ 19 ] and Barbetta et al. [ 6 ], and both suggested that the different financial incentives are actually the key driver behind the different results in performance.

The study by Bøgh Andersen and Jakobsen [ 16 ] suggested that non-clinical practices, such as wait times, differ between public and private sectors, but in terms of clinical practices, organizations operate similarly. Kondilis et al. [ 37 ] found that PFP hospitals have lower bed capacity, lower occupancy rates and lower nurse staffing rates compared to public hospitals. Staffing rates were also discussed by Daidone and D’Amico [ 20 ] who found that PFP hospitals work in slightly over-staffed conditions for medical staff while public and especially PNFP hospitals are over-staffed by technical and administrative staff.

Numerous important theoretical contributions suggest that private hospitals should outperform public hospitals in terms of efficiency [ 19 , 31 , 52 ]. However, as we have seen, the empirical evidence from the regulated and mixed healthcare markets in Europe is much more diverse. Although many studies reported insignificant results, the majority of the remaining studies found that public hospitals perform better than PNFP providers, which, in turn, show slightly better performance than PFP hospitals in terms of efficiency measures (see Table 3 ). This result is in line with the conclusion in previous review studies, such as Hollingsworth [ 33 ] who summarized his findings as follows: “Cautious conclusions are that public provision may be potentially more efficient than private, in certain settings.” Tiemann et al. [ 50 ] concluded that in line with the evidence found in studies from other countries, especially the US, the evidence from Germany suggested that private ownership (i.e., PNFP and PFP) is not necessarily associated with higher efficiency compared to public ownership.

The last part of the Hollingsworth quote is important as it points to the discussion we launched in the introduction of this paper. Namely, that the context is important for understanding the results. Several studies discussed the specifics of the financing system, the contracting process and the degree of competition or monopoly in the market as important factors in determining the effects of ownership. In general terms, it appears likely that results are sensitive to specific circumstances and regulatory setup. Or as stated in one of the previous review studies,” [t]he true effect of ownership appears to depend on institutional context, including differences across regions, markets, and over time” [ 23 ].

Drawing on the theoretical contributions from the introduction, we speculate that variation in the results across countries and over time may be partially explained by differences in transaction costs, market structure and market maturity. High transaction costs may affect efficiency results for private providers more than for public providers, as administrative burdens may be internalized by public organizations. Market structure is a key issue as monopolies are likely to lead to lower efficiency, whether public or private. This means that diverging results across studies may be explained by underlying variations in market structure. Market maturity may also influence results across studies. As explained in the introduction, cost reductions tend to be highest in the first rounds of competitive bidding, while private and public agents adjust over time. Unfortunately, the studies did not report systematically on transaction costs, market structure or market maturity.

In terms of the ownership argument presented in the introduction, several countries operate with different types of private ownership, and PNFP organizations tend to do well in comparison with their PFP counterparts. The main explanations suggested in the studies point to the difference in profit orientation and the motivation of employees as key factors for explaining this. However, more research should be devoted to explaining these observations, based on the differences in the structure, operational practices and historical role of not-for-profits in specific institutional contexts.

Another theoretical point (usually not addressed clearly) in comparative public–private provider studies is that the political reasons for using private actors can vary significantly and that this is likely to have impact on the results. Contracting out can be done for purely ideological purposes. It may be done to save costs, to increase the service and quality or to boost a market and promote the development of private enterprise. This means that the use of private actors can be successful from some perspectives but not from others.

An important observation from the present review is that many studies that addressed the economic effects of ownership failed to account for quality and operational differences, such as patient selection, although this is potentially very important for the economic results. This represents an important barrier for cross-study comparison, as the tendencies regarding economic performance may be associated with different outcomes in different studies and contexts. An underlying reason for this observation is the challenge of measuring quality consistently. The literature distinguishes among input, process and outcome quality. Many studies focused on the two first dimensions as proxies for the overall quality, as it is easier to obtain data on these issues. However, the real test of benefits to patients lies in the outcome quality. There are extensive efforts to improve the collection of such data in many countries, but this effort has not yet been sufficiently integrated in efficiency studies.

In addition to the theoretically based explanations, there may be specific methodological explanations for the diverse results. Shen et al. [ 46 ] investigated such issues (also [ 23 ]. They found that variation in the direction and size of ownership effects can be explained by differences in research focus and methodology as described above.

Another methodological issue is that the number of studies and underlying cases included in this scoping review may be insufficient to show clear patterns. This argument is somewhat contradicted by the fact that this study can be seen as an extension of previous review studies, which also tended to show mixed results with a slight tendency to favor public and PNFP organizations as shown above.

Overall, it seems fair to conclude that contextual circumstances can be at least as important as ownership. Furthermore, that we need more systematic analysis of the dimensions of the context in order to find patterns in the relationship between contextual circumstances and performance for public and private providers.

This paper investigated whether there is evidence that private delivery organizations perform better than public delivery organizations in European healthcare systems. This topic was studied using a scoping review of the available evidence from recent studies conducted within the European region. We identified 24 studies that reported economic efficiency measures or quality in their comparison of hospital organizations with different ownership forms. The studies covered a wide range or European countries, including Austria, Germany, England, France, Greece, Italy, Spain, Switzerland and Norway. The majority of the studies ( n  = 17) found in the database searches addressed the economic performance of public and private specialized care organizations. Seven studies addressed quality.

In terms of economic performance, most studies focused on technical efficiency using DEA or SFA techniques. Fifteen studies compared PUB hospitals to PFP hospitals. Some studies reported technical, cost and profit efficiency (see Table 3 ). About half of these studies reported that public hospitals are superior to PFP hospitals in efficiency. Most of the other studies found insignificant differences. Only one study reported that PFP hospitals have better profit efficiency. Eight studies compared the performance of PFP hospitals and PNFP hospitals. The majority of these studies found that PNFP hospitals are superior in terms of technical, cost and profit efficiency. Only one study pointed to responsiveness as a performance measure where PFP hospitals are better than PNFP hospitals. Finally, we found 11 studies compared PUB hospitals and PNFP hospitals. Most of these studies reported insignificant differences. In the remaining studies, we found slightly more studies presented PUB hospitals as superior to PNFP hospitals.

Summing up, our review of 17 studies representing more than 5500 hospitals across Europe showed that public hospitals are most frequently reported as having the best economic performance compared to PNFP and PFP hospitals. PNFP hospitals are second, while PFP hospitals are least frequently reported as superior. However, a sizeable number of studies did not find significant differences. In terms of quality, the results were mixed, and it is not possible to draw clear conclusions about the superiority of an ownership type. A few studies analyzed patient selection. They indicated that public hospitals tend to treat patients who are slightly older and have lower socioeconomic status, riskier lifestyles and higher levels of co-morbidity and complications than patients in private hospitals.

This scoping review pointed out shortcomings in the available studies, and future studies are needed to investigate the relationship between contextual circumstances and performance. A significant weakness in many studies was the failure to account for quality, patient selection and other operational dimensions, which may have influenced the results. This weakness should also be addressed in future comparative studies.

Abbreviations

Average length of stay

The American Society of Anesthesiologists

Body mass index

Corrected ordinary least squares

Data envelopment analysis

Diagnosis related group

Percutaneous coronary intervention

Probability of default

Private for-profit

Private not-for-profit

Public–private partnership

Randomized controlled trial

Standard deviation

Stochastic frontiers analysis

Social Health Insurance

Specialist treatment center

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Acknowledgements

We would like to acknowledge the research group of the project Privatizing the health care sector: Expansion of voluntary, private health insurance and private for-profit hospitals in the Nordic countries funded by the Norwegian Research Council (Grant No. 238133).

The study was funded by the Norwegian Research Council (Grant No. 238133, Privatizing the health care sector: Expansion of voluntary, private health insurance and private for-profit hospitals in the Nordic countries). The funding body was not involved in the study.

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LKT and KV designed the study together. KV was responsible for data collection with an information specialist. LKT sorted the abstracts which were then checked by KV. LKT was responsible for drafting the manuscript and analyzing the data. KV contributed especially in writing the theory and background sections and discussion. The final data analysis and writing of the manuscript were done jointly by LKT and KV. All authors read and approved the final manuscript.

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Tynkkynen, LK., Vrangbæk, K. Comparing public and private providers: a scoping review of hospital services in Europe. BMC Health Serv Res 18 , 141 (2018). https://doi.org/10.1186/s12913-018-2953-9

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Over the last few decades, numerous studies have analysed performance differences in the healthcare sector between public and private hospitals across the world.

When delivering healthcare services, can public hospitals outperform private ones? Or is it more likely the other way round?

A major argument in favour of the private sector providing public services is that it could increase service efficiency. But there is mixed evidence that confirms with certainty whether private organisations in the healthcare sector perform better than their counterparts. 

This opens up another question: if private organisations providing public services could lower costs and increase efficiency , what would happen to their public counterparts?   Earlier studies on privatisation tend to give a higher performance ranking to public services provided by privately-owned organisations, but this performance gap has attenuated over the last few years.

Although several studies demonstrate that publicly-owned hospitals in the United States are less efficient than those that are privately-owned, other findings challenge this logic and provide evidence that private hospitals are the ones that tend to be less efficient.   In Europe, several studies show different trends. In Belgium, for instance, publicly-owned hospitals are on average more efficient than their private counterparts. In Germany, some studies show a similar pattern, but others reveal that there are no significant differences in cost efficiency between public and privately-owned hospitals. 

In Asia, public hospitals experience higher costs per patient than those that are owned privately, while in Australia, there are no differences in costs between public and private hospitals.   To clear up these mixed results, we conducted research analysis across healthcare studies for the USA, Germany, Taiwan, Belgium, Spain and Italy using data from public and private hospitals.

In Belgium, publicly-owned hospitals are on average more efficient than their private counterparts

We compared the countries’ differences in both healthcare costs and performance levels . Our aim was to demonstrate whether public organisations in the healthcare sector performed better than private ones or vice versa. Our findings bring good news for public hospitals.

Financial costs and efficiency – who wins?

Some scholars have suggested that because public sector organisations operate without market pressures, they cannot benefit from the information the market provides to improve their performance . Instead, they rely on political will and budgetary changes: both aspects that can limit their production levels.    Regardless of this, our analysis shows a genuine effect in favour of public sector hospitals. We found evidence that the provision of health services is cheaper if provided by the public sector.

Indeed, public sector hospitals outperform their private counterparts when the goal is to reduce financial costs. This is good news for governments and taxpayers: public health services are cheaper and allow for better financial savings.

However, there is a secondary aspect where private hospitals are better: productive performance. The findings show that when technical efficiency is considered, the private sector performs better than its public counterparts.

Public sector hospitals outperform their private counterparts when the goal is to reduce financial costs

Performance differences between countries

When measuring healthcare performance by country, the findings showing that private hospitals tend to be more efficient do not hold for the United States and Germany.    All our estimations for the United States show better performance in public hospitals . Our analysis of German hospitals also finds a similar pattern: public hospitals in Germany tend to be more associated with better performance while private hospitals perform worse.   A possible explanation for these results can be found in the public sector’s performance levels by country published in the World Economic Forum’s Global competitiveness report. According to the report, Germany and the US rank similarly and are identified as having the best performing public sectors worldwide.    On the contrary, Taiwan, and particularly Belgium, Spain and Italy – the four remaining countries in our study – rank much worse in terms of public sector performance.    Our analysis demonstrates that comparing public and private performance requires a broader framework that includes several moderating factors that go beyond whether ownership is public or private. Only by developing further research on these additional factors will we be able to distinguish when and how private organisations could be a better option for delivering health services.

This article is based on joint research by Esade and the Research Institute of Applied Economics published in the International Public Management Journal.

Visiting professor, Department of Strategy and General Management at Esade Business School

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Nurses Deserve Better. So Do Their Patients.

By Linda H. Aiken

Dr. Aiken is a professor of nursing and sociology and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

The Covid-19 pandemic exposed strengths in the nation’s health care system — one of the greatest being our awesome nurses. But it also exposed many weaknesses, foremost among them being chronic nurse understaffing in hospitals , nursing homes and schools .

More nurses died of job-related Covid than any other type of health care worker. The more than 1,140 U.S. nurses who lost their lives in the first year of the pandemic knew the risks to themselves and their families. And yet they stayed in harm’s way. They cared for their fallen co-workers. They went to New York from around the country to fight on the front lines in the first Covid surge. Nurses from Northwell Health in New York returned that support by deploying to the Henry Ford Health System in Detroit in December when a surge occurred there.

We celebrate nurses now. We call them heroes. But if we value their sacrifices and want them to be there when we need them, we must prevent a return to the poor prepandemic working conditions that led to high nurse burnout and turnover rates even before Covid.

As a nurse with extensive clinical experience in hospitals, I found it nearly impossible to guarantee safe, effective and humane care to my patients. And so I established the world’s leading research center on nursing outcomes to understand the causes of nurse understaffing in the United States and abroad and to find solutions to the problem.

The United States has a robust supply of nurses . And there is no evidence that recruits to nursing have been deterred by Covid. To the contrary, applications to nursing schools increased during the pandemic.

Death, Through a Nurse’s Eyes

A short film offering a firsthand perspective of the brutality of the pandemic inside a covid-19 i.c.u..

I was looking through the window of a Covid I.C.U. And that’s when I realized I might see someone die. I didn’t even know who she was. But I was filled with immense grief as she edged closer to death by the hour. What I didn’t know yet was that by the time I left just two days later, at least three patients would be dead. The vaccine offers hope, but the sad truth is that the virus continues its brutal slaughter in I.C.U.s like this one in Phoenix, Ariz. The only people allowed in are health care workers. They’re overworked and underpaid in a deluged hospital. I wanted to know what it is like for them now, after a year of witnessing so much death. Eager to show us their daily reality, two nurses wore cameras so that for the first time we could see the I.C.U. through their eyes. “Unless you’re actually in there, you have no idea. Nobody can ever even imagine what goes on in there.” [MUSIC PLAYING] This I.C.U. contains 11 of the hospital’s sickest Covid patients. Most of them are in their 40s and 50s. And they are all on death’s door. It’s an incredibly depressing place. I blurred the patients faces to protect their privacy. But I also worried that blurring would rob them of their humanity. The family of this patient, the one who is rapidly declining, allowed her face to be shown. And they readily told me about her. Her name is Ana Maria Aragon. She’s a school administrator and a 65-year-old grandmother. Sara Reynolds, the nurse in charge of this I.C.U., organized a video call with Ana’s family to give them a chance to be with her just in case she didn’t make it. “It just breaks my heart when I hear families saying goodbye.” You might expect the doctors to be running the show. But it is really the nurses who are providing the vast majority of the care. “We do everything. We give them baths every night.” “Rubbing lotion on their feet.” “Shave the guys’ faces.” “Cleaning somebody up that had a bowel movement. It doesn’t even register as something gross.” “Look, I walk into the room. I say, hey, sounds like you have Covid. And I might order a chest X-ray. I might order blood work. I might order catheters. All that stuff is done by the nurse. I may have spent 10 minutes. The nurse might spend seven or eight hours actually in the room, caring for them. Let’s say there was a day that nurses didn’t come to the hospital. It’s like, why are you even opening?” “Ibuprofen.” 12-hour-plus shifts, isolated in this windowless room, these nurses survive by taking care of each other. “Aww, thank you.” And by finding small doses of levity. [MUSIC - JAMES BAY, “LET IT GO”] “(SINGING) Wrong. Breeze.” “I’m getting older now, and there’s all these new young nurses coming out. And I feel like a mom to all of them. Morgan, she’s got big aspirations. She loves to snowboard, and she’s so smart. And Deb, Deb’s just— she’s funny.” “I tease her all the time. I can tell her to do anything, and she’ll just do it because I think she’s scared of me because I just always say, make sure you have no wrinkles in those sheets.” The patients spend most of their time on their stomachs because it makes it easier to breathe. But the nurses have to turn them often to prevent pressure sores. There was one woman in her 50s who was so critical that this simple procedure risked killing her. “Even just turning them on their side, their blood pressure will drop. Their oxygen levels will drop.” “Her heart had actually stopped the day before. And so the concern was if it was going to make her heart stop again.” “Then come over. Push.” “We were all watching the monitors.” “I felt relieved like, whew, we did it.” Arizona’s a notoriously anti-mask state. And it faced a huge post-holiday surge in Covid cases. In January, the month I was there, Arizona had the highest rate of Covid in the world. As a result, I.C.U.s like this one have too many patients and not enough nurses. “Because they’re so critical, they need continuous monitoring, sometimes just one nurse to one patient with normally what we have is two patients to one nurse. But there definitely are times when we’re super stretched and have to have a three-to-one assignment.” A nurse shortage has plagued hospitals over the past year. To help, traveler nurses have had to fly into hotspots. Others have been forced out of retirement. Especially strained are poorer hospitals like Valleywise, which serves a low-income, predominantly Latino community. “Many of our patients are uninsured. Some of them have Medicaid, which pays something but unfortunately not enough.” This means they simply can’t compete with wealthier hospitals for nurses. “There is a bidding war. The average nurse here, give or take, makes about $35 an hour. Other hospitals, a short mile or two away, might pay them $100.” “We lost a lot of staff because they took the travel contracts. How can you blame them? It’s sometimes a once-in-a-lifetime opportunity to make a lot of money.” “Every single day I’m off, I get a call or a text. ‘Hey, we desperately need help. We need nurses. Can you come in?’” This nursing shortage isn’t just about numbers. “Physically it’s exhausting. We’re just running. We don’t have time to eat or drink or use the restroom.” “They have kids at home, doing online school. And I think, gosh, they haven’t even been able to check on their kids to see how they’re doing.” “My days off, I spend sleeping half the day because you’re exhausted. And eating because we don’t get to eat here often.” Nurses have been proud to be ranked the most trusted profession in America for nearly two decades. But during Covid, many worry they aren’t able to uphold the standards that earned them such respect. “I can’t give the quality of care that I normally would give.” “It’s absolutely dangerous.” “That’s demoralizing because we care. We’re nurses. It’s our DNA.” Ana had been in the hospital for over a month. Her family told me she was born in Mexico. She came to the States 34 years ago, first working in the fields before eventually landing her dream job in education. She’s beloved at her school. Former students often stop her in town and excitedly shout, Miss Anita. She was very cautious about Covid. She demanded her family always wear a mask and yelled at them to stay home. Yet, tragically, she somehow still caught it. “She had been declining over the course of several days. It’s a picture we have seen far too often that we know, this one is going to be coming soon.” Because there is no cure for Covid, the staff can only do so much. Once all the ventilator settings and the medications are maxed out, keeping a patient alive will only do more harm than good. So Ana’s family was forced to make a tough decision. “And I talked to family and let them know that we have offered her, we have given, we have done everything that we can, there’s nothing more that we can do. The family made the decision to move to comfort care.” “If I’m there while someone’s passing, I always hold their hand. I don’t want somebody to die alone. That’s something that brings me peace.” “Thank you.” “Thank you.” “Dance floor is packed. People hugging, holding hands, and almost no one wearing a face mask.” “I think like many health care workers, I’m angry a lot. And my faith in humanity has dwindled.” “How can you think this isn’t a real thing? How can you think that it’s not a big deal?” “Free your face. Free your face.” Arizona Gov. Doug Ducey has advocated for personal responsibility over mask mandates even though he’s been photographed maskless at a gathering and his son posted a video of a crowded dance party. “Even on the outside, they go, I don’t care. I’m not wearing a mask. I’m not getting the vaccine. That’s bullshit. The second they come into the hospital, they want to be saved. Never do they say, ‘I made the decision. I’m accepting this. Don’t do anything, doctor.’” Half a million people in this country have died from Covid. Many have been in I.C.U.s with nurses, not family members holding patients’ hands. “I always wonder, are they still going to be there when I get to work? It’s on my mind when I get home. Are they going to make it through the night? There’s one that I can think of right now.” One patient in his late 50s was so critical that he required constant supervision. Each of his breaths looked painful. “There was one day that he was kind of— he was looking a little bit better. And so he was able to shake his head and smile. And we set up a video call for him. And it was just the sweetest thing ever. I could hear his little grandson— he was probably 4 years old or so. And I saw him on the screen, too. And he was just jumping up and down, so excited. ‘You’re doing it, Grandpa. You’re doing it. We love you. Look at you. You’re getting better.’ It just broke my heart. It broke my heart. He’s one that I don’t think is going to be there when I get back on Sunday.” But I’d already been told something Sara hadn’t. The patient’s family had decided to take him off life support. “Yesterday they did? Oh. And I just think of his little grandson. And ‘you’re doing it, Grandpa. You’re doing it.’” He wasn’t the only patient who didn’t make it. When I went back to the hospital, I noticed that the bed of the patient I’d seen get flipped over was empty. My heart sank. I knew this meant she’d passed away. “What’s sad is when I go back, those beds will be full. They’ll have somebody else there just as sick with another long stretch of a few weeks ahead of them before it’s time for their family to make that decision.” I’d never before seen someone die. And even though I didn’t know these people, witnessing their deaths left me sleepless, exhausted, and depressed. It’s unfathomable to me that these nurses have gone through that every single week, sometimes every single day for an entire year. I assumed the nurses must block out all the deaths to be able to keep going, but they don’t. They grieve every single one. “I’ve always loved being a nurse. It’s what I’ve always wanted to do. And these last couple months, it’s definitely made me question my career choice.” And what makes their situation so tragic is that many of these nurses hide their trauma, leaving them feeling isolated and alone. “We’re the only ones that know what we’re going through. I don’t really want to tell my family about everything because I don’t want them to feel the same emotions that I feel. I don’t want them to know that I carry that burden when it— that it is a lot. I’m Mom. I’m strong. I can do anything. And I don’t want them to see that.” Leadership in the pandemic hasn’t come from elected officials or spiritual guides but from a group that is underpaid, overworked and considered secondary, even in their own workplaces. As so many others have dropped the ball, nurses have worked tirelessly out of the spotlight to save lives, often showing more concern for their patients than for themselves. I worry their trauma will persist long after we re-emerge from hibernation. Covid’s legacy will include a mass PTSD on a scale not felt since World War II. This burden should not be ignored. “Thank you. Thank you. I feel, yeah. And you’re all amazing.” [MUSIC PLAYING]

Nevertheless, we find ourselves too often with a shortage of nursing care. Many decades of research reveal two major reasons: First, poor working conditions, including not enough permanent employer-funded positions for nurses in hospitals, nursing homes and schools. And second, the failure of states to enact policies that establish and enforce safe nurse staffing; enable nurses to practice where they are needed, which is often across state borders; and modernize nurse licensing rules so that nurses can use their full education and expertise.

Training more nurses cannot solve these problems. But more responsible management practices in health care, along with better state policies, could.

Not only are states not requiring safe nurse staffing, but individuals also do not have the information and tools they need to pick hospitals and nursing homes based on nurse staffing or to advocate better staffing at their hospitals and nursing homes.

Ninety percent of the public in a recent Harris Poll agreed that hospitals and nursing homes should be required to meet safe nurse staffing standards. But powerful industry stakeholders — such as hospital and nursing home organizations and, often, medical societies — are strongly opposed and usually defeat legislation.

The New York State Legislature is the first in the postpandemic era to fail to approve proposed safe nurse staffing standards for hospitals. The legislature passed a bill that did not require safe nursing ratios, opting instead for internal committees at hospitals to oversee nursing and patient safety. This happened despite compelling evidence that the legislation would have resulted in more than 4,370 fewer deaths and saved more than $720 million over a two-year study period through shorter hospital stays.

What are the solutions? While there are some actions the federal government could take, the states have most of the power because of their licensing authority over occupations and facilities. The hospital and nursing home industries have long failed to police their members to remove the risk of nurse understaffing. So states should set meaningful safe nurse staffing standards, following the example of California, where hospital nurses cannot care for more than five adult patients at a time outside of intensive care. State policies are tremendously influential in health care delivery and deserve greater public attention and advocacy, as they are also ripe for exploitation by special interests.

In states with restrictive nurse licensing rules, many governors used their emergency powers during Covid surges to waive restrictions. If they were not needed during a national medical emergency, why are they needed at all?

Still, the federal government has a role to play: It should require hospitals to report patient-to-nurse staffing ratios on the Medicare Hospital Compare website, because transparency motivates improvement. The federal government could incentivize the states to pass model nurse practice acts.

We need influential champions taking on special interests so that states will make policy changes that are in the public’s interest. AARP is using its clout to advocate nurse-friendly policies. But health insurers and companies such as CVS, Walgreens and Walmart that provide health care have been on the sidelines.

While we long to go back to pre-Covid life, returning to chronic nurse understaffing in hospitals, nursing homes and schools would be a big mistake. We owe nurses and ourselves better health care resources. The so-called nurse shortage has become an excuse for not doing more to make health care safe, effective and patient-centered. State legislators must do their job. Health care leaders must fund enough positions for nurses and create reasonable working conditions so that nurses will be there to care for us all.

Linda H. Aiken is a professor of nursing and sociology and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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An earlier version of this article misstated the status of legislation on nurse staffing standards in New York State. The bill passed without setting minimum nursing ratios; it did not fail to pass.

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603 Hospital Essay Topic Ideas & Examples

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• Uniform Hospital Discharge Data Set The data is used in the administration of Medicaid and Medicare programs and the standardization of health care. The UHDDS allows the government and health care facilities to have comparable data that can be used […]
• Supporting Services at Hospitals: Nutrition, Pastoral Care, Patient Ombudsman and Social Services With regard to a facility’s support functions, there are environmental services, which address two key areas of patient care in the hospital. We will write a custom essay specifically for you by our professional experts 808 writers online Learn More
• Operations Management Strategies at Arnold Palmer Hospital In the case of a hospital, some major considerations that are necessary to factor in are the movement of personnel and patients.
• SAP Implementation in a Hospital To unveil the reasons behind the success of this implementation, this paper addresses such aspects as major peculiarities of the process of implementation, challenges, driving forces and restraining forces to the change, factors contributing to […]
• SWOT Analysis of the Hospital The hospital has been in existence for the past 100 years growing from a small community hospital to its current size The hospital is a community icon The hospital boasts facilities for tertiary care […]
• Aravind Eye Hospitals: Process Innovation in Healthcare In the case of Aravind, it is the recruitment and training of the paramedical staff of the right qualification. This directly explains the lack of Aravind’s equivalent in the Western world, as there is a […]
• Hospital Strategic Management and Planning: Adding Value The development of value-adding strategies starts with singling out the requirements and the analysis of the quality of services. Market research and target marketing are essential elements of pre-service value-adding as they help to plan […]
• Fairbanks Memorial Hospital: Break Even Analysis The hospital is one of the 75 that are owned by the Conglomerate of Health Services of America. The main challenge is to convince the CEO that Better Care Clinic is a financially viable inclusion […]
• Arnold Palmer Hospital’s Operations and Supply Chain Supply chain management refers to the management of a network of interconnected businesses in a supply chain that may be involved in the provision of the packages goods or services required by the end customer.
• The Database Design for a Hospital Management System The paper focused on the database design for a hospital management system. A report on database design, implementation, and limitation formed the conclusion of the paper.
• Performance Management System in Hospital This will be carried out through interviews with managers of various hospitals and employees, in order to have a clear picture of how the sector is influenced by the existing performance management system.
• A Hospital Emergency Room General processes in the emergency room are kept at a minimum in order to attend to patients as soon as possible.
• Clinical and Business Solutions for Hospital Improvement One of the methods is to enhance patient outcomes and cut costs by extending pharmaceutical care medication therapy management to a set of patients insured by a shared-risk contract. One of the most crucial methods […]
• Elmwood Hospital and Concerned Community Coalition Dispute While the CCC is merely a coalition of residents protesting for change, the current board of trustees has legitimate power over the hospital’s resources and future projects. Firstly, the board should demonstrate its superior negotiating […]
• Patient Safety in Hospitals Patient safety is one of the primary concerns of the healthcare system. The organization of the nursing staff is among the factors that influence the way the care is provided.
• Johns Hopkins Hospital’s Organizational Analysis The mission of the Johns Hopkins Hospital is to enhance the health of the community and the world by establishing a standard of patient care.
• Third-Party Intervention at Lincoln Hospital High turnover in organisations leads to increased recruitment costs and the training of new employees to fill the gaps that are left by the outgoing employees.
• Fall Prevention Strategies in the Hospital Setting The multidisciplinary nature of the nursing intervention is expected to ensure consistency of results and a more reliable improvement across the setting.
• The Rural Hospital: Mission Statement A secondary mission of the hospital is to improve the lives of the whole community through competent organization and timely psychological, social, and adaptive support.
• Latifa Hospital’s Management Plan Given the growth in the healthcare sector in the UAE, it is imperative to develop a management plan for the Hospital.
• Nurses’ Role in Hospital Infections Prevention In this respect, nurse should express greater awareness of the seriousness of the problem through recognizing and monitoring the rates of infections caused by insufficiently protected healthcare setting for patients.
• How to Start and Manage a New Hospital 00 Activity Budget for Hospital Project The following is the estimated amount of patients to be treated at the new facilities in the hospital. 0 $363,000.
• Hospital Nurses’ Perceptions About Distractions to Patient-Centered Care Delivery Distractions in a patient-care delivery setting are a huge barrier to the delivery of timely and high-quality care. Such evaluation is critical to the sustainability of high-quality and timely patient-centered care delivery.
• Hospital Infection as Legal Issue in Healthcare The duty of care establishes that it is the mandate of the healthcare practitioners to provide adequate patient information and ensure the safeguarding of the patient’s well-being.
• Stevens District Hospital: Analysis and Goals They focus on the vision to formulate strategic goals while focusing on the changing demands of both the physicians and the target patients.
• Assessing the Performance of Riverview Community Hospital The statement of operations of the hospital showed that the hospital created a surplus in the years reviewed. In 2005, the revenue of the hospital was $26.
• Hospital Operations Mismanagement: Causes and Implications of It Alternatively, a hospital with mismanaged hospital operations may handle patients inadequately during an outbreak and thus lead to the spread of disease around the institution’s environment.
• The Royal United Hospital: Barriers Affecting Delivery of Quality Healthcare The primary focus of this paper is to discuss some of the barriers that have proved to be daunting to both the hospital and the wider population and how these challenges may be alleviated.
• Hospital Discharge Planning The main goal of the process of discharge planning is to facilitate continuity of care. However, studies have shown that there is a lack of equivalence between experts and decisions that are made in the […]
• Competitor Profile of Montefiore Medical Center and New York–Presbyterian Hospital The hospital is a university hospital of Albert Einstein College of medicine located in Bronx, New York. The hospital receives a large percentage of funds from the New York local government and the federal government.
• Barriers to Healthcare Facility Security: The Johns Hopkins Hospital Within such circumstances, the alertness and attention of healthcare professionals are doubled because the increased facility security implies that a number of critical controls are growing. The potential solutions must be developed to protect staff, […]
• The Children’s Hospital of Philadelphia Employee Handbook The employee handbook provides an employee with the information on company’s policies, provided benefits, and describes the responsibilities of the employee.
• SWOT Analysis of Jackson Memorial Hospital One of the major strengths of Jackson Memorial Hospital there is its size and the fact that it allows professionals to develop further.
• The Sullivan Hospital System Some of the problems show that SHS management has been slow to keep up with trends in the industry. Management has to have it in mind that employees in the organization have been trained in […]
• Atrium Health Hospital Network Atrium health is a leading provider of full-spectrum medical services to communities in North Carolina and South Carolina. Advanced equipment that aid in the treatment of different health problems, such as digital mammography machine and […]
• Hardy Hospital’s Materials Management Caroline, the Director of Materials Management, evaluates the flow of materials in the hospital from the store to various hospital departments and the other way around.
• Dubai Private Hospitals’ Product Hierarchy The concept of product is increasingly becoming popular in the business sector, especially when it comes to explaining the sequence of movement and distribution of products on the basis of demand and market competition.
• Competitor Analysis: Burjeel Hospital Burjeel Hospital has state-of-the-art facilities that enable it to provide high quality care to its patients. The market dominance of the hospital enables it to use several strategies to defend its market share.
• HRM Analysis – Children’s Hospital This is the group of people which composes the core labor market from which Children’s Hospital and all other employers in the area have to choose from. In the context of technology, IT has brought […]
• Great Western Hospital: Case Analysis High-risk pregnancy care is an area of great attention because of the potential danger of specific conditions for pregnant women’ and newborns’ health and even lives.
• Nightingale Community Hospital: Corrective Action Plan In the light of the fact that the hospital needs some improvements, the key values pursued by the team will be helpful for restructuring the general heath care strategy, and improve the managerial performance in […]
• WestLake Research Hospital’s Data Privacy Issue The main limitation of the hospital is the lack of a good software system to ensure the safety of the patient data from breaching.
• Outsourcing of Hospital Services: Strategic Capacity Planning The majority of all advantages were connected to the possibility to increase the level of satisfaction of the staff. Finally, the possibility to fill in working places may lead to the creation of a possibility […]
• King Fahad Hospital’s Force Field Analysis By applying FFA to the mentioned issues, the present paper will uncover the forces which resist the change, as well as the forces that support it and, therefore, can be used to combat the effects […]
• Social Worker in a Hospital These key vales, ethics and principles include; Understanding the hospital and the health services given by the hospital Planning for release from hospital Support in adjusting to ill health Giving counsel and emotional support Providing […]
• The Drawbacks of the At-Will Employment in the Hospital Despite that, at-will employment is neither beneficial for the employer nor the employee due to the absence of fundamental responsibilities from both sides.
• Mt. Sinai Hospital’s Expansion Problem Sinai hospital is that, out of the 90 beds, it is difficult for the management to determine the number of beds to be allocated to surgical staff for surgical patients and the number of beds […]
• The JCI Hospital’s Quality Program Evaluation 2 section requires the quality program to support the selection of the measures throughout the hospital besides coordinating and integrating measurement into the systems of the facility.
• Rashid Hospital’s Strategic Planning and Its Results According to the interviewees, this is needed to help the hospital team to identify the best healthcare strategies and effectively respond to the changes that are occurring within the framework of the healthcare industry.
• University of Utah Hospital’s Stakeholder Analysis The first internal stakeholders are the procurement; they buy goods that of high quality to ensure success in the management process at the hospital.
• The Discussion of Leahi Hospital Honolulu The cost of medical care is also a major cost driver, as medical and surgical services are often the most expensive services provided in a hospital. In addition, the cost of providing quality care is […]
• Memorial Hermann Hospital’s Health Information Management The interview was enlightening and instructive, providing insight into the day-to-day operations of HIM at an extensive hospital system, the field’s difficulties and prospects, and the position of HIM in the larger healthcare environment.
• Emotional Intelligence among University Hospital Nurses Even though it is challenging to overestimate the importance of self-management and its competencies, University Hospital nurses state that this domain brings a few inefficiencies in the medical organization.
• Quality of Healthcare Delivery at Palmetto Hospital The vision to improve the quality of healthcare delivery at Palmetto Hospital in Miami Dade implies a fundamental change in the structure of the institution.
• Hospital Facility Planning Needs For this reason, the facility takes an approach of embracing change, adapting, and actively striving to provide safe and high-quality care in an unpredictable, complex, and ever-changing environment. Careful consideration of these factors will ensure […]
• The 21st-Century Role of US Hospitals The development of new medical technologies, such as x-rays and antibiotics, and the expansion of medical education and research led to a growth in the number of hospitals and the services they provided.
• Servant Leadership at St. Jude Children’s Hospital The results of the hospital’s work are exceptional, which allows us to state that the Christian mission to serve people is fulfilled.
• How to Reduce and Prevent Hospital Readmissions The main idea is to ensure “coordination and continuity” of health and nursing care for patients and their families to understand their treatment goals.
• Covenant Hospital: Mission Statement Therefore, the manager should comprehensively comprehend the time of the week when there is significant traffic of patients to every of the Covenant Hospital’s four clinics.
• Unsafe Staffing Ratios at Kendall Regional Hospital Currently, the nurse-patient ratios at Kendall Regional Hospital’s ICU present a significant problem as the shortage of nurses affects the quality of care and patient outcomes.
• Scarlet Hospital Offensive Marketing Plan The hospital, in an effort to improve the quality of healthcare services as per its offensive marketing plan, will require additional funds.
• Hospital-Acquired Infections After COVID-19 Measures The exposure variables were based on the changes made in 2020 to IPC measures and the rapid increase in hand hygiene.
• Nursing Redundance: Public Hospitals in Western Australia Nurses monitor the evaluation and diagnosis in the care units and discharge patients, a repetitive functionality that can be done by other staff. Coordination is essential in nursing; there is redundancy due to miscommunication in […]
• Alternative Ways of Customer Segmentation: Bethesda Hospital Case Scenario Therefore, supporting all potential consumers is crucial since it aims to increase the strategic and rigor of a company’s initiatives while fulfilling what the Bible teaches believers about meeting the needs for everyone. Need-based segmentation […]
• Recommendations for Hospitals to Address Marketing Mix The recommendation for improving the price of the services in the hospital is to pass new pricing politics. The place of the hospital is one of the essential factors for the hospital’s development.
• Discussion of the Atrium Hospital Project Scope However, in the scope of the project, there is also a need to evaluate the potential outputs to form an idea of what kind of results will be presented to the customer.
• Constraints and Ways to Address Them: The Atrium Hospital One of the biggest concerns for the Atrium is the compatibility of the new EPIC with the automated operation of intravenous pumps, special devices that control the delivery of fluids, including medications, into the patient’s […]
• Hospital-Acquired Condition Reduction Program In my work environment, this payment system relates to the evaluation and implementation of practices to prevent the spread of HAIs and the ongoing monitoring of practices to improve patient safety.
• Healing Hands Hospital’s Change Goals Such an approach will create motivation for healthcare experts and allow Healing Hands Hospital to take the leading role in the market and have a competitive edge.
• Hospital’s Administrative Team: The Importance of Communication When stepping in the shoes of the nurse who had to communicate with the hospital commander on the issue of inappropriate leadership, I would ensure the following. Patient care in the military is more complicated […]
• Project Management in Hospital and Doctor’s Office Key stakeholders and sponsors are also a part of the scheme team to work with the owner, management, IT support, nurses, doctors, paramedics, and the finance team.
• The Impact of the Current Onboarding Process on Employee Engagement at the Hospital The adaptation of employees to the peculiarities of the work process is a critical criterion that reflects the effectiveness of management and the sustainability of measures taken to involve and retain professional employees.
• Older Patients’ Transition From a Hospital to a Nursing Home The example of transition of care chosen for further exploration is concerned with the transition of care from the hospital to the nursing home setting for patients that came to receive healthcare for various conditions.
• Hospitals vs. Physician’s Offices Private physician offices, on the other hand, acquire the bulk of the revenue in outpatient procedures. Nonetheless, the profit is more accentuated both in a hospital setting and for private practitioners.
• Strategies for Hospital Preparedness Facilities managers are mandated by medical institutions to offer a thorough strategy that enables the effective distribution of resources for the upkeep of structures and systems.
• Transitional Infant Care Speciality Hospital’s Value Chain This case study highlights TIC’s value-addition and position in the healthcare industry value chain, presenting an argument that charismatic leadership and innovative technology made the facility a top-tier healthcare facility in Pittsburgh.
• Hospital Pressure Injuries Resulting From Falls The proposal deals with hospital pressure injuries resulting from falls and other factors among the acute care in-patient, investigating and examining the issue to offer a solution for hospital-acquired pressure injuries.
• The 104-Bed Health City, Cayman Islands Hospital It is evidenced in the article that their high-quality care model is practiced in all of Narayana’s health facilities which include the HCC.
• Hospital Electronic Communication With Patients Virtual visits and video chats became the main methods of doctor-patient and nurse-patient interaction at Cleveland Clinic, especially during the ongoing COVID-19 pandemic.
• Strategies to Improve the Safety of Patients at Hospital Consequently, it is critical to discuss the impact of internal and external factors on the feasibility of the project. The most pressing problem is the growing number of LEP patients in the United States and […]
• Decision-Making in Hospital Management Disputes A decision against the union will drastically affect the upcoming contract negotiations, while a decision in favor of the union would give nurses the power to overturn management decisions.
• Motivational Interviewing in a Hospital The approach can be helpful in behavioral change as it promotes offering guidance and helping people to appreciate what is in it for us.
• Infection Control at Massachusetts General Hospital With a budget of more than $750 million annually, MGH was the largest receiver of money from the National Institutes of Health in 2011 and managed the country’s most extensive hospital-based research program.
• Nursing Practice Intervention in Acute Hospital Accordingly, it is crucial to include EBP in the nursing curriculum to advance nursing science and improve nursing care for aspiring nurses.
• Price Variation Among Commercial Insurers for Hospital Services Usually, HMOs will require members to pick a primary care physician from the organization’s network of providers. A PPO is a type of managed care organization that does not require members to select a primary […]
• The Arnold Palmer Hospital Project Management Other members of the project team will be the executive director and director of the facilities department. Lastly, patients and the community will be stakeholders in the given project since they will be treated.
• Acute Renal Failure and Hospital Readmission On the other hand, the case reveals that long-term care does not have measures to ensure that patients eat the required diet and engage in appropriate activities to protect their well-being.
• Miami University Hospital: Performance Scorecard This scorecard is employed to evaluate the medication safety in the unit by assessing the overall process of medication distribution and access, as well as the rates of patients who are administered controlled substances.
• Hospital Readmissions Prevention Planning The plan involves the assessment of patient learning needs, the assessment of barriers to learning, and the identification of relevant topics.
• Avon Hospital: Organizational Structure The board of directors counsels the executive team, and the IT manager is also on the hospital’s leader board. The board of directors counsels the executive team, and the IT manager is also on the […]
• The Analysis of the Environment of the Jackson Behavioral Health Hospital The analysis of the environment in which a healthcare institution operates reveals the characteristic factors and drivers that determine the success and effectiveness of activities and highlights the key barriers and challenges, including those related […]
• Watson Community Hospital: The Electronic Health Records System A case study on Watson Community Hospital addresses the problem of poor physician support and describes the strategy for updating the current electronic health records system in the company.
• Patients’ Difficulties in Navigating Hospitals Thus, the system may relieve the overall stress caused during the whole stay of a patient in the organization, from admissions to receiving treatment.
• Functional Areas to Add Value to Hospital Services In order to improve the performance of Paradise Hospital, it is necessary to identify the main areas where value added will positively affect the hospital and patients.
• Discussion: US Non-Profit Hospitals In this case, the inhabitants’ taxes are a waste of money and equal medical care is an unobstructed assurance impossible to provide.
• Perceptions About Non-Profit Hospitals The prejudice that non-profit hospitals are in low-income areas may be justified. Thus, government assistance to non-profit hospitals can have a negative effect and increase their hospitality, but to the detriment of the community.
• Informational Technology Applications to Facilitate Hospital Expansion Figure 1 shows how the responsibilities and stages of the process are currently distributed: Currently, the process of shifting patient data into digital space is occurring gradually in the U.S.healthcare system.
• Jackson Behavioral Health Hospital: Overview It is the responsibility of the medical clinic management team to establish initiatives that enhance the optimal performance of the institution.
• Financing in Healthcare: Hospital and Solo Practice The fourth stage, billing, is where hospitals and solo practice physicians send the information to the insurance carrier once the charges have been entered.
• Hospital Staff Mental Health During the Pandemic The second theme that was discussed in many of the studies reviewed is the variety of factors that were involved in this issue, worsening the conditions of the health workers.
• The Working Hours of Hospital Staff Nurses and Patient Safety The last two sections of the research article describe in detail the emerging conclusions, limitations, and lessons for transforming the future of the healthcare sector.
• Variations in Hospital-Based Outcomes This variation in the quality of care can be due to some factors, namely the experience and training of the hospital staff, the availability of resources, and the hospital’s policies and procedures.
• Types of Workforce and Staffing Data in the Hospital Setting As per the evaluation and metrics, provided in the table below, the grand total of workforce in the organization is equal to 3288 staff workers.
• Economic Stability Initiatives for Hospitals The common approach to address the problem is to increase communities’ awareness about the importance of health through lectures and fairs.
• Orlando Health Hospital: Shared Values The health mission of the OHH organization is “to improve the health and quality of life of the individuals and communities”.
• Diversity and Inclusivity in the Hospital Namely, the organization will have to set goals that will guide its members to understand the significance of diversity and inclusion.
• Mission and Vision Statements for Steven’s Hospital The result of the search for solutions to the issues can be considered the formation of a paradigm of value-based approach and the construction of a clear vision and mission in the provision of medical […]
• Best Care for Older People in Hospitals The most effective care for older persons is possible through a collaborative approach to treatment that proactively incorporates the patients, their families, and an interdisciplinary team.
• Pressure Ulcers at King Fahad Hospital High cases of PU significantly involve the quality of preventive care provided, and they are often used to measure the quality of nursing care in a hospital. Poor nursing practice and administration are the significant […]
• Anywhere Hospital’s HIM Case Study Considering the requirements or prohibitions of using the function in EHR, the American Health Information Management Association points to the possibility of errors in documentation with misuse of the function.
• Middleville Hospital’s Electronic Health Record One factor that could be evaluated is the ability of the EHR to create a digital environment in the hospital that contributes to the overall quality of care, including that of non-medical and administrative aspects.
• Texas Health Arlington Memorial Hospital’s Analysis Keywords: hospital, administrative structure, mission, and vision When evaluating a healthcare institution, one would typically seek the characteristics that reflect the efficacy of healthcare management and the performance of the staff in order to pass […]
• Workforce Planning Policy in Hospital In addition, the HR manager should review the technological, environmental, political, and sociological aspects of the external environment to ensure that the workforce plan complies with the current conditions.
• Hospital-Reported Outcomes: The Benefits of Health Information Exchange In the case of effective exchange of data on all gaps, the threat of their recurrence is minimized, which is one of the main tasks of implementing hospital reporting systems. Employees’ responsibility is increasing, which […]
• Patient-Reported and Hospital-Reported Outcomes PROs and HOs also greatly vary in terms of the degree of objectivity and the extent to which they are aligned with verifiable facts.
• Administration Errors in a Mental Health Hospital The selection of a representative group from the population of interest is among the prerequisites for the production of reliable and generalizable results.
• Improving Hospital Protocols, Procedures, and Activities Second, vulnerability assessment is the strategy that can aid the medical network in the event of a crisis, and emergency preparedness operations are utilized to restore and protect the IT architecture of a business.
• Hand Washing and Hospital-Associated Infections The specific aim of the interdisciplinary plan is to increase the level of compliance in the organization in question with the help of the introduced changes and innovations, as well as address the low motivation […]
• Quality Improvement Initiatives in Hospitals First, hospital authorities identify and investigate the AE by finding the responsible people for the AE, rating the severity of the AE, and identifying the path for an adequate response.
• Hospital Safety Climate and Incidence of Readmission The National Quality Forum and the Agency for Healthcare Research and Quality have decided to focus on the connection between HP and the safety of patients.
• A New Patient-Centric Strategy at the Wilton Hospital Patients come to the facilities to receive medical attention; therefore, it is a tragedy for them to depart without receiving any treatment while at the health facility. For the hospital to develop, patients should be […]
• Stanford Hospital’s Business Model Assessment Tricare is an essential part of the healthcare system in the United States, and it plays a vital role in ensuring that hospitals can provide the best possible care to their patients. Medical product manufacturers […]
• A Violent Client at Bellevue Hospital Since I had a better understanding of the norms of the surrounding culture, I was able to communicate in a positive manner to avoid creating conflicts.
• Hospital Capacity Analysis and Recommendations On the one hand, the efficiency of 99% demonstrates that the healthcare organization properly uses all the available resources and does not waste them.
• King Fahad Hospital-Madinah’s Health Policy Analysis Therefore, it is the responsibility of healthcare administrators and the government to develop policies that guide and promote the accepted codes of conduct regarding employees’ behavior in the workplace. Indeed, the policy content includes the […]
• Ellen Zane’s Actions of Sustainability at Tufts-NEMC Hospital The CEO held a series of town meetings throughout the night and day with the physicians and other staff revealing the financial facts, targeted growth initiatives, and general topics she considered worthy of their knowledge. […]
• Importance of Efficient Hospital Pharmacy Management According to the scholars, the Pharmaceutical Department’s response “provided effective support for prevention, control and treatments of COVID-19” and minimized the virus’s spread among the patients and the staff. The choice of effective pharmacy management […]
• Checking Into Hospital: Possible Risks It is important to note that this is a risk that is difficult for patients to mitigate because, in most cases, they do not know what medicine they require, the quantity, and how often the […]
• Hospital-Acquired Infections and Personal Hygiene The aim of the work is to consider the intervention in the context of nursing theory, as well as to analyze the implementation plan and possible problems.
• Case Study of the Chifley District Hospital The effective functioning of the healthcare system requires the availability of professional medical personnel, the development of infrastructure and resource provision, and the improvement of the organizational system.
• Strategic Plan for Desert Hospital The mission is ‘raison d’etre’, it explains the purpose of the existence of the organization, to motivate both internal and external stakeholders to make their contribution to the development of the hospital.
• Human Resource Management in German and Turkish Hospitals Today, much attention is paid to the field of human resource management and development and the application of various factors to achieve improvements, promote changes, and deal with challenges.
• How Billing and Collections Mistakes Constrain Hospitals’ Revenues In the modern healthcare system, many financial and organizational processes define the quality of care and satisfaction of all stakeholders, including the medical staff and patients.
• Mount Carmel Mental Health Hospital’s Framework It remains the only hospital with in-patient psychiatric and mental health care in Malta after the closing of the psychiatric unit at Mater Dei Hospital in 2020, and the construction of a new mental health […]
• Online Healthcare Education Program in Hospitals The program is necessary for the healthcare market due to the likelihood of adoption by the target group, doctors and nurses working in critical care departments in busy hospitals.
• Food Waste in American Hospitals Even in other settings where food is served, consumers’ expectations and the quality of the food and food service determine the decision to finish the food.
• The Issues of Staffing in Hospitals and the Shortage of Nurses The two issues that I selected for a deeper exploration are staffing in hospitals and the shortage of nurses. In summary, the two issues reviewed in this essay are the shortage of nurses and staffing […]
• Hospital-Acquired Pressure Injury During the patients’ time at the hospital, the primary care for them is provided by and the responsibility of the nurse practitioners.
• The Inpatient Hospital Atrium Health Organization In other words, one can easily draw a logical conclusion that the organization is creating ad building a project to improve research, innovation, and community health.
• HR Department Sections in Hospitals The main aim of manpower planning is to estimate the number of people for the successful work of an organization. Recruitment specialists search for new employees and lead them through all the stages of employment.
• How to Minimize Patient Falls in Hospital Settings Numerous studies have been conducted recently to develop and establish a single framework that can help reduce the frequency of patient falls at all hospitals nationwide.
• Night Shift Nurses’ Breaks in Hospitals The goal of the study by Landis et al.was to describe and understand the lived experience of night shift nurses taking breaks in hospitals, as well as the implications of this phenomenon in the workplace.
• Improving HRM at Krisna Hospital The fact that patients are willing to communicate with PCEs rather than physicians and follow the recommendations of the former can be seen as an influential factor contributing to the breach of the psychological contract.
• Investment Management in an Expanding Hospital It is clear that one of the administrative team’s first questions is to determine the type of funding that should be resorted to for the purposes of the hospital organization.
• The Issues of Hospital: Clinical Time Log and Journal This challenge is significant for the hospital since the failure to emphasize the necessity to adhere to the specialists’ recommendations might gradually deteriorate the health status of the affected category of citizens.
• Cape Coral Hospital’s Training and Organizational Development The success of the programs will require the organization to have a chief diversity officer to steer the training in the direction it needs to go.
• The East Orange General Hospital Clinic’s Organization Readiness The question is as follows: Can the clinic staff create an adequate educational base for patients compared to the previous communication gaps to reduce the number of follow-up appointments missed?
• The Hospital-Physician Integration and the Hospitalist Model The hospitalist model is perfectly suited for growing physician-hospital integration, providing an efficient workflow to increase the satisfaction of both physicians and their patients.
• Prevention Bundle to Reduce Hospital-Acquired Pressure Injuries in Critical Care The evaluation of the severity of pressure injuries is done with the Braden scale. The high-risk intervention was developed to facilitate recovery in patients with higher stages of pressure injuries.
• The Ottawa Hospital: Recommending an Evidence-Based Practice Change The Ottawa Hospital is one of the most admired in Canada. There is a necessity to improve the system and encourage patients to use it.
• Strategic Plan to Implement an EMR System Project in a Fictional Hospital Unit Before choosing the vendor and testing the technologies, the first step was to find the prominent leaders who would prepare the staff for the changes.
• The East Orange General Hospital: Practice Gaps This paper aims to discuss the question of why patients do not return to the clinic for their follow-up appointment and explore how this practice gap can be addressed in the East Orange General Hospital.
• Bethesda Hospital’s Market Segmentation This type of segmentation is likely to affect marketing in such a way that the company will be able to reduce the cost of advertising and purchasing activities.
• Wilful Blindness and Whistleblowing in Australian Hospitals According to this theory, the crisis in the social system and the self-understanding may be the reasons for willful blindness among the executives of the healthcare facilities.
• Saint Anne’s Hospital Neighborhood in Fall River, Massachusetts Further, the housing statistics in Fall River and the current state of St. Saint Anne’s Hospital and the nearby church of the same name are centers of the nicest neighborhoods in Fall River.
• Incivility Within Hospital Metaparadigm These stress-causing actions of Incivility reduce the effectiveness of the nurses and their ability to offer patient care. Incivility should be reduced by the measurements set by the hospital organization to help in the effectiveness […]
• Aspects of Databases in Hospitals Nevertheless, it is also valid that a large number of external sources might slow down the speed of data processing and reduce the overall accessibility.
• Bayside Memorial Hospital MRI Project’s Costs The cash flow projected from the sale of the MRI at the end of the project’s five-year life cycle is included in Year 5 net cash flow.
• Community Standard Marketplace Technology of Hospital The assessment of community standard of care competition based on the results of the conducted needs analysis in the selected healthcare facility should be performed with regard to the principal characteristics of this area.
• Phelps Hospital: Where the Rubber Hits the Road This paper seeks to discuss the financial issues of the hospital, along with the strategies and recommendations to be involved to help resolve the economic problems.
• Modern Trends in Healthcare in Hospitals
• General Healthcare Technology Trends at Miami Valley Hospital
• Discussion of Journal of Hospital Infection Benefits
• Incivility in the Workplace: Hospitals Against Violence
• Influenza Vaccination of Healthcare Workers in Acute-Care Hospitals
• Blackstone Hospital: New Employee Training Guide
• Smiley Hospital’s Problems and Their Solution
• Nurse Staffing and Education and Hospital Mortality Post Answer
• Safety Precaution in Hospital for Patients and Nurses
• Catholic-Affiliated Hospitals’ Advance Medical Directives
• Northwell Health, New York: Long Island Jewish Hospital Network
• Hospital Advertising Decision-Making
• St. James Hospital: System Planning
• Guy’s Hospital Building and Its Context
• Data Management at Three Big Worldwide Hospitals
• Hospital’s Liability
• Arcadia Hospital: 2005 and 2006 Financial Statement Ratio Assessment
• Hospital Readmissions Reduction Program Policy
• The Promise of Telehealth for Hospitals
• The Implementation of Kangaroo Care in Hospitals
• Patients With Cancer: The Importance of Early Referrals to Hospitals
• The 2018 Financial Results of Clinch Hospital
• Infection Prevention in Hospitals: The Importance of Hand Washing Among Surgical Nurses
• MRSA Strain on the Rise in US Hospitals: Root Cause Analysis
• Patton-Fuller Community Hospital: Capital Project Proposal
• Modularization of Hospital for Capturing and Delivering Value
• The Hospital Telehealth Adoption
• Nurse-Patient Ratio and Massachusetts Saint Vincent Hospital Strike
• Hospitals Performance Measurement
• New Harbor Memorial Hospital’s Culturally Competent Service
• Organizational Development Intervention for City Center Hospital
• Cross-Cultural Training for New Harbor Memorial Hospital
• Golden Age Hospital: Quality Control and Accreditation
• University Hospital Sharjah Fall Prevention Assessment
• Golden Age Hospital: System Organizations and Functions
• Golden Age Hospital: Market Research & Segmentation
• Hospital Quality Improvement Plan
• Prevention of Heart Failure Hospital Readmissions
• “Patient Satisfaction With Hospital Care and Nurses in England” by Aiken
• Barnes – Jewish Hospital: Policy Proposal
• Emergency Disaster Preparation in the Hospital
• Challenges and Opportunities Faced by Hospitals in Urban Communities
• Al Amal Hospital: Fall Prevention Strategy
• Teleworking Impact on Employees in King Faisal Hospital
• Nurse Leader and Abbott Northwestern Hospital
• Performance Improvement at a Hospital and Research Center
• Nightingale Community Hospital’s Negative Trends
• Prevention of Hospital-Acquired Infections Among Pediatric Patients
• King Edgar Hospitals Trust: The Leadership Improvements
• Nursing Shortage in ABC Hospital
• Motivating Employees: Kaluyu Memorial Hospital
• Abbott Northwestern Hospital: VBP
• Hospital-Acquired Infections: Epidemiology and Risk Factors
• Hospital Readmission and Health Related Quality of Life in Patients With Heart Failure
• Hospital Analysis. Banner Health
• Marketing Plan About Maternity and Children Hospital in Saudi Arabia
• The Good Samaritan Hospital: Marketing Research
• Planning and Budgeting: Greenville Hospital System Medical Center
• Reflection on “Concept of Hospital Readmission” and “Tele ICU Concept Analysis”
• Al Okhdood Hospital: Marketing Plan
• Issues Facing Hospitals in the United States
• Increasing Hospital Efficiency
• The Rise and Prevention of Staph Infection in Hospitals
• Hillcrest Memorial Hospital: Employee Motivation and Empowerment
• Variability in Hospital Care of Rape Victims
• Foreign Nurses in the United States’ Hospitals
• King Fahad Specialist Hospital Assessment
• Risk and Emergence Management in a Hospital
• Community Hospitals Integrating With Other Organizations
• Hospital Cost Shifting: Challenges and Opportunities
• Development of Bedsores in the Hospital
• Constraints to the Hospital Operations Plan
• Ethical Code of Conduct for XYZ Acute-Care Hospital
• The Attitudes of Acceptance and Resistance Toward Computerization in Hospital
• Hospital Operations Mismanagement: Healthcare Organizations
• Antiseptic Solution in a Hospital Setting
• Antiseptic Scrubbing Solutions in Hospitals
• Nursing Practice: Hospital and Home
• Home Health Care vs. Telemonitoring: Reducing Hospital Readmissions for Patients With Heart Failure
• Specialty Hospitals and Community Hospitals
• Mission and Services in Children Hospital in LA
• Marketing Promotion Strategy for a Hospital
• Quality Outcome at the Advocate Good Samaritan Hospital
• Medical Care Quality: C.W. vs. Regional Hospital
• The Culture in the Al Rahba Hospital
• Consulting for the Caring Angel Hospital
• “Pre-Hospital Oxygen Therapy” by Branson & Johannigman
• Hospital Information Systems and Statistics: Timeline
• Trackare: Hospital Information Systems and Statistics
• St. Agnes Hospital’s Human Protection Policy
• Child Birth at Home and in the Hospital
• St. Barnabas vs. Lincoln Hospital: In Search for the Best Medical Assistance
• Epidemiology: Hospital-Acquired Infections
• Reducing Medicaid and Local Taxing District Support to Florida’s Public and Not-for Profit Hospitals
• Nurse’s Perspectives on Medication Safety in Critical Care Units in Saudi Arabian Hospitals: A Pilot Study
• ST. Joseph Hospital Healthcare Compensation Plan
• Migrant Friendly Hospital Initiative
• Achieving Safe Staffing for Older People in Hospital
• Communication and Leadership Problem: Sunrise Hospital
• Northwestern Memorial Hospital: The Customer Service Model
• The NHS Trust Hospital: Factors That Affect the Attainment of Superior Healthcare Services
• The Hospital Quality Improvement Activities
• The Royal United Hospital Bath: Evaluating Quality System
• Health Care Quality Assessment of Al Amal Hospital
• SWOT Analysis for Virginia Commonwealth University Hospital
• Hospital Quality Programs Comparison
• Management Analysis: Alberta Health Services Hospital
• Financial Analysis of Patton-Fuller Community Hospital
• Ultra Violet Light in Decontaminating Hospital Setting
• Healing Hospital: Healthcare Facilities’ Aims
• Reducing the Number of Call-Ins in the Hospital
• The Risk Factors Associated With Hospital Falls
• Hospital Benchmarking Using Data Envelopment Analysis
• Scandals in Corporate Accounting Systems at the Hospital
• Nurse Burnout Across Army Hospital Practice Environments
• Goodscan Company vs. Hospitex Hospital
• The Communication Processes at St. Duke’s Hospital
• Bartlett Hospital: Healthcare Marketing Plan
• Evaluation of the Culture Dimensions Impact in Hospital Setting
• Staffing and Quality of Care in Hospitals: Ethical Concerns
• Patients Lawsuits and Their Families Against Hospitals
• The Problem of Patient Falls in Hospitals
• Budget Process and Performance Appraisal at Al Baraha Hospital
• Dubai Hospital Overview & Analysis
• Hospital Information Management & Medical Records
• Functioning of the Customer Service in AL Baraha Hospital
• The Hospital Fatimah School of Nursing
• Veterans Affairs: Hospitals and Marketing
• The Safety Net Hospitals: Role and Functions
• The St. Mary’s Wildcat Hospital: Patient Billing System
• Long-Term Care Hospital: Changes in Control Mechanism
• Hospital Merger: Situation Analysis
• Code of Ethics in Jewish General Hospital
• Veterans Affairs Hospital Accreditation
• Magnetic Structure of Moore Regional Hospital
• Healing Hospital: A Daring Paradigm
• Veterans Affairs Hospital Risk Management Program
• Veterans Affairs Hospital Utilization Management Program
• Suing Hospitals for Denying Breaks to Hourly RNs
• The Biographic Data of the Area for Hospital
• Organizational Structure and Culture Within Hospital
• On the Use of Physical Restraints in Hospital Settings
• Renfrey Memorial Hospital Board Project Proposal
• The Diversity in The Johns Hopkins Hospital
• The King Edgar Hospital’s National Health Service Trust
• A Veterans Affairs Healthcare Program to Deliver Hospital Care in the Home
• King Edgar NHS Hospital’s Trust Issues
• Shriners Hospitals: Financial Report and Improvements
• Sunnylake Hospital SWOT Analysis
• Correct Handwashing Techniques in a Hospital
• Quality Frameworks in King Faisal Specialist Hospital & Research Center
• Wayne Memorial Hospital’s Learning Needs Assessment
• Organizational Design and Culture in Hospitals
• Deming’s “PDSA” Cycle in the Lehigh Valley Hospital
• Hospital-Acquired (HAI) or Nosocomial Infections
• The FGI Guidelines in the Hospitals
• Independent or Governmental Accreditation of Hospitals?
• Medication Errors at Riyadh Military Hospital: Medical Safety and Quality
• Strategic Planning of Bloomington Hospital Administration
• Brigham and Women’s Hospital: Shapiro Cardiovascular Center
• Development Specification for Hospital Cleanliness
• Market Orientation of the Community Hospital
• The Chief Executive Officer of Hospital: Collaboration With Administrative Staff
• The Provision of Healthcare: Hospitals as a Key Institutions in the National Health Care Structure
• Current Economic Environment and Hospitals: The Interrelationship Between the Health Sector and Economic Welfare
• Multi-Hospital Systems: Experience in Safety Net Hospitals
• Place of Dying for Ill People: Home Versus Hospital
• Budgeting in Healthcare and Financial Management of Hospitals
• University of Washington: Dental School and a Hospital Within the Campus
• Interpretation in American Hospitals: Scholarly Position
• Decision-Making at the Memorial Hospital
• Department-Wise Profile of a Specialty Hospital: How It Works in Modern Conditions
• Health Information System for a Small Hospital and the Present Day Healthcare Environment
• White Memorial Hospital in East Los Angeles: A Not-For-Profit, Faith-Based, Teaching Hospital
• Process of Professional Integration in Hospitals and Expansion of Managed Care Health Insurance
• Physician-Hospital Arrangements and Development in the Healthcare Industry
• Structural Design Changes in Hospitals and Patient-Focused Care
• Hand Hygiene Essence in Healthcare Setting and the Adequate Change of Hospital Culture
• Healthcare Data and Decision Making: Case of All Saints Hospital
• IT Infrastructure in the Lahey Hospital and Medical Center
• Saving Hospital’s Reputation and Downsize Its Staff
• Hospital Discharge Data Set in Relation to Race
• Factors of Patients Expectation in Hospitals: Evidence From Private and Public Sectors
• Teaching Isolation Precautions Among Hospital Visitors
• Public Health Crisis: Hospital-Based Violence Intervention Programs
• Healthcare It Governance: Information Management in the Hospital Setting
• Moodle Learning Management System in a Hospital Operating Room
• A Strategic Change of the Hospital for Developing and Improving Overall Efficiency
• How You Can Improve Your Hospital Birthing Process
• Green Supply Chain With ISO 14001 and 9001 in Australian Hospitals
• American Hospital Association Structure and Operation
• Hospital Stakeholders: Roles, Responsibilities, and the Relationships
• The Economy of North Island Hospital and Competition in the Medical Market
• The Lack of Parking Spaces in the Civil Hospital of Brescia
• Private Hospital in Kuwait: Strategic Design
• Educational Levels of Hospital Nurses and Surgical Patient Mortality
• Health Services: Cultural Competence in Hospital Settings
• Minimizing Risk of Patients Falling Within a Hospital Premises
• Procedures of Implementation Policies in Hospitals
• Infection Control Among Pediatric Patients at St. Mary’s Hospital
• Hospital-Acquired Venous Thromboembolism Studies
• Clinical Nurse Educator Role in Swan Hill Hospital
• Johns Hopkins Hospital: Enhancing Patient Safety
• Use of Electronic Health Records in United States Hospitals
• Identifying a Hospitals Practice Problem for Improvement
• Hospital-Acquired Infections: Quality Improvement
• Healthcare Pathway Choice in a Hospital
• Blackwell Medical Center: Hospital vs. School of Medicine
• Unified Patient Portfolio Across the UAE Hospitals
• Organizational Structures and Leadership in Hospitals
• Organisational Commitment in Teaching Hospitals
• Accounting Ethics in Hospital Settings
• Hand Hygiene in Hospital Environments
• Akron Children’s Hospital: An Request for a Proposal
• High Waiting Time in Abu Dhabi Hospital
• A Leader’s Style at a Hospital
• Hospital Comparison in Denver, Colorado
• Transactional Leadership Style at a Hospital
• Media Highlight of a Suicide at a Mental Hospital
• White Memorial Hospital: Countertransference and Limitations
• Environmental Standards for a Hospital
• Human Behavior in Fire: Petersburg Hospital
• Akron Children’s Hospital’s Service Quality
• Christian Northeastern Hospital Nurse’s Interview
• Hospital Design and Safety Measures
• Saint-Joseph Hospital’s Inbound Marketing
• Non-Profit Hospital’s Financial Challenges
• Hospital Neglect: Premature Baby Suffers Burns
• Northwestern Memorial Hospital Managing Diversity
• Al Razi and Ibn Sina Hospitals’ Merger Advice
• Al-Hammadi Hospitals Company’s Analysis
• Academic Medical Hospital’s Six Sigma Adoption
• USA Hospital Supply Management and Challenges
• Model of Operations Management in Hospital
• NW Hospital Baltimore OCAI Assessment
• St. Randall Private Hospital’s Primary Filing System
• Rashid Hospital’s Strategic Fall Prevention Plan
• Al-Ain Hospital’s Waiting Line Management
• Northwell Hospital’s Annual Survey Database
• Hospital Integration Solutions in the Erie Region
• Arnold Palmer Hospital’s Global Operations Strategy
• Establishing a Cancer Treatment Unit in a Hospital
• Intelligent Hospital Pavilion ICU: Video Analysis
• Supplying Medical Equipment to Hospital
• Hardy Hospital SWOT Analysis
• MedStar St. Mary’s Hospital Cultural Reform
• Trinity Community Hospital’s Cancer Service Line
• Greenville Hospital System’s Managerial Accounting
• Administrative Assistant to a Hospital Director
• Patton-Fuller Community Hospital Virtual Organization
• Managing a Hospital Budget
• Patient Care Quality and Safety in American Hospitals
• Improving the Quality of Service Delivery in Hospital
• Hospital Readmission Causes in Australia
• Hospital Administrator on Duty’s Emergency Response
• Active Shooter Exercise Scenario for Hospitals
• King Faisal Specilaist Hospital’s Quality
• New York – Presbyterian Hospital: Organizational Analysis
• Management Strategies in Hospitals: Best Practices
• Academic Dental Hospital: Patient Flow Improvement
• King Faisal Specialist Hospital & Research Center Analysis
• Labor Shortages Counterstrategies in US Hospitals
• Mismanagement at Respiratory Hospital Departments
• Jackson Memorial and the University of Miami Hospitals
• Infection Prevention in Hospitals: Hand Washing Importance
• Hospital Efficient Design and Employee Satisfaction
• Quality, Cost, Delivery Implementation at Hospital
• Mercy Hospital: Consultative Change Recommendations
• US Hospitals Increasing Financial Performance
• Forest Hills Hospital: Patient Safety Improvement
• Community Hospital’s Stakeholder Analysis
• Jackson Memorial Hospital: Rebranding Assignment
• Mercy Hospital’s Patient- and Family-Centered Care
• Prairie St. John’s Hospital’s Administration
• Hospital Outpatient Prospective Payment System
• Hospital Facilities’ Payment Challenges
• King Edgar NHS Hospital Trust’s Performance Change
• Royal Liverpool University Hospital’s Design Project
• The Stennis Hospital: Daycare Services for Patients
• Quality Medical Services in Hospital’s Staff Perception
• Gloucestershire Hospitals National Health Service
• Gloucestershire Hospitals Operations Management
• West Bloomfield Hospital’s Six Sigma Implementation
• Electronic Health Records in a Small Hospital
• New Hospital for Women and Babies: Video Analysis
• Emory Hospital’s Employee Efficiency and System Theory
• Abbott Hospital’s Acquisition and Human Resource Issues
• St George Hospital’s Healthcare and Business Management
• Group Productivity Improvement in Hospitals
• Sepsis 30-Day Hospital Readmission Prevention
• Sheikh Khalifa Hospital and Cleveland Clinic Hospital
• The Risks Associated With Hospital Operations
• Hospital-Acquired Influenza Among the US Children
• Healthy Diet at Los Angeles Children’s Hospital
• Hospital’s Risk Management Program Analysis
• Brazosport Memorial Hospital Quality Improvement Program
• The Culture of Patient Safety in Hospitals
• Houston Methodist Hospital Quality Assurance Approaches
• Layout at Arnold Palmer Hospital’s New Facility
• Utilization at Houston Methodist Hospital
• Utilization Management at Hospital
• GE Healthcare Company: Medical Ethics and the Lack of Access to Hospitals
• The Plight of Pharmacists at Tertiary Hospital
• Freedom Hospital Geriatric Patient Analysis
• US Hospitals and the Civil Rights Act of 1964
• Lifecare Hospital: Accounting Information System
• Hospital-Acquired Diseases and Infections
• Mismanagement at Hospital Respiratory Units
• Patient Length of Stay in Hospitals as an Indicator of Efficiency for the Health System
• Hospital Quality Improvement
• Rainbow International Children’s Hospital’s Plan
• Hospital-Laboratory Contract and Information Privacy
• Nonprofit Organizations and Hospital Financing
• Making a More Efficient Hospital
• Error Proofing Strategies in Hospitals and Educating Healthcare Workers
• Capability Audit in the Hospital’s Functioning
• Huggins Hospital’s Facility Management Strategy
• Hospital Settings, Services, Integrated Delivery System
• Health Information Technology Job in Hospital
• New Medical Center Specialty Hospital in Abu Dhabi
• Children’s Hospital of Philadelphia: Network Strategy
• University Hospital Sharjah: Strategic Management
• 21st-Century Solutions Health Care Hospital
• Abbott Northwestern Hospital’s Leadership and Delivery
• Forest Hills Hospital’s Quality Improvement
• Metrics in UAE Innovative Hospital Design Project
• King Saud General Hospital’s Nursing Educational Program
• Paradise Hospital: Value Proposition in Patient Care
• Golden Age Hospital and Elderlies in Mission Viejo
• Hospital Competition and Strategic Planning
• Anchor Hospital’s Telemedicine Services
• Well Care Hospital’s Administration: Legal Aspects
• La Verne Medical Hospital Center Project
• Kaluyu Memorial Hospital’s Employee Motivation
• Saint Vincent Hospital’s Product Lifecycle Management
• UAE Hospital Strategic Management and Planning
• UAE Innovative Hospital Design for Patient Safety
• Hospital Strategic Management and Planning
• Dallas Hospital’s Emergency Preparedness
• Caring Angel Hospital’s Goals and Action Plan
• Forest Hills Hospital’s Organizational Leadership
• ABC Hospital’s Effective Team Building
• Hospital Strategic Management: Balanced Scorecard
• Afya Hospital’s Recruitment of Volunteers
• Bay Community Hospital’ New Equipment
• Dayton Children’s Hospital and Community Service
• Lifeline Hospital’s Quality Improvement Program
• Scarlet Hospital’s Marketing Campaigns
• Health Law After Simkins vs. Cone Memorial Hospital
• Hospitals’ Total Quality Management and Leadership
• Tertiary Hospital’s Employee Behavior by Maslow
• Tertiary Hospital Pharmacists’ Challenges
• Mercy Hospital’s Relations and Communication Issues
• St. Aidan’s Hospital: Work Motivation Problem
• General Hospital’s Conflict Resolution
• Peel Memorial Hospital Balanced Scorecard Solution
• King Hussain Hospital’s Decision-Making Issue
• Hospital Operating Room: Innovative Change Model
• King Abdullah University Hospital’s Accounting System
• Hospital Staff Support, Education, and Training
• Modular Construction in Hospital Buildings
• Stafford Hospital: Leadership and Governance Problem
• Learning From Crisis: Hospital and Military Examples
• St Peter’s Hospital’ Management and Morale
• Burjeel Hospital Primary Research and Data Analysis
• Health Inequities in Simkins vs. Moses H. Cone Memorial Hospital
• Patient’s Stay Time in the Hospital: Forecast
• NHS Hospital Business Management
• End of Life Issues: Hospital Versus Home Death
• SouthCoast Institute Hospital: Health Services Planning
• The Burjeel Hospital Outpatient Services Quality
• Burjeel Hospital Outpatient Care Quality
• The Internet Use at MD Anderson Cancer Hospital
• Al Ain Hospital: Managing Organization And People
• LLB Service Quality: UAE Hospitals Leadership and Service
• UAE Hospitals: Transformational Leadership and Service Quality
• Judy’s Hospital: Patient Admission Process Improvement
• Hospital Workers Unionization: Arguments Against
• Al Ain Hospital Total Quality Management
• The Red Cross Hospital Project Management
• Springfield Central Hospital: Medication Errors Case
• Hospitals Business Process Management: Bureaucratic Aspect of the Work
• Central Michigan Hospital Changes
• The Burjeel Hospital: Waiting Time and Customer Satisfaction
• Hospitals Security Upgrade: Terrorist or Criminal Actions
• Purchasing MRI Equipment for Nonprofit Hospital
• Florida Hospital: Organizational Theories
• St. Margaret’s General Hospital Marketing
• Sinai Hospital Baltimore: Organizational Structure and Improvement
• Khalifa Hospital’s Measuring Customer Satisfaction
• Analysis of Management at St. Peter’s Hospital
• Antimicrobial Practice in Hospitals: Pharmacokinetics and Pharmacodynamics
• Kings County Hospital Center Company Analysis
• Flushing Hospital Medical Center Strategies
• Trinity Community Hospital Development
• ISO Standards Implementation on TQM Strategies at Sheik Khalifa Hospital
• Queens Hospital Center Organizational Assessment
• Strategic Plan – Social Media in Women and Child Hospital
• Development of an Online Business Expansion for Mercy Hospital in Miami, Florida
• Deciding on the Potential Hospital Location
• Healthcare Marketing: John Hopkins Hospital
• King Faisal Specialist Hospital and Research Center (KFSH&RC) in Riyadh, Saudi Arabia
• Talent Management at Stamford Hospital
• Financial Management: Johns Hopkins Hospital
• The American Hospital Association (AHA) Workforce Issues
• HR Management at the Patient Care Hospital
• How Hospitals Integrate Career and Continuous Training Programs
• Communication in Hospital Emergency Department
• Quality Management at Memorial Hospital
• Management at Stamford Hospital
• The Liability Imposed to Medical Practitioners and Healthcare Organizations in the United States – Point of View by Writes & Dent
• Bronson Methodist Hospital Quality Pursuit
• Mafraq Hospital Strategic Operations
• Operations Management: Arnold Palmer Hospital and Hard Rock Cafe
• Implementing Telemedicine Solutions: Grand Hospital
• Strategic Planning in the IT Department of the New Castle Hospital
• Transformation at Duke University Hospital
• A Case Against the Unionization of Registered Nurses in Hospital
• Florida Hospital: Nurses Turnover
• Integrated Health System at the St. Louis Hospital
• The University of Kentucky Hospital
• Marketing and Strategic Plan: Hope Network Hospital
• Hospital Scrubbing Solution
• Hospitals Aim to Keep Older Nurses on the Job by Increasing Safety
• Merger of Western Hospital and Academic Hospital
• Trinity Community Hospital
• NHS Trust Hospital Transformation
• Public Budgeting Issue in a Hospital
• How to Decrease Turnover and Increase Retention of Nurses in General Surgical Floor of the Hospital
• Current Changes and Challenges in Hospital/Physician Relations
• Culturally Bound Innovation in Romanian Clinic and Research Hospital
• The Benefits of Implementing Global Standards (GSI Health Care) at King Faisal Specialist Hospital and Research Center
• Various Internal and External Stakeholders and the Duty of Loyalty to Them, on the Example of the Hospital
• Recommendations for Burke Rehabilitation Hospital Staff Organization
• International Expansion Strategy of Australia Cancer Care Hospital.
• Health Information Management System: Sohar Hospital
• Service Organisation: Duke Children’s Hospital
• The Problem of Lack of Trained Staff in Queens Hospital
• A New Alcohol and Drug-Abuse Rehabilitation Center in Liverpool Hospital, Sydney
• The Hospital and Management
• Management of Sir Charles Wilberforce Hospital
• John Hopkins Hospital: Creating a Safety Culture
• Supply Chain Management in Hospitals and H1N1 Crisis in KSA
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IvyPanda . "603 Hospital Essay Topic Ideas & Examples." March 2, 2024. https://ivypanda.com/essays/topic/hospital-essay-topics/.

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Advantages Of Government Hospitals (Essay Sample)

Hospitals are universally accepted as the place of healing. There are two types of hospitals: a private hospital and a government owned hospital. A private hospital is owned either by family, or a group of companies and are usually quite more expensive in terms of payment than a government owned hospital wherein most of the costing are either free or cheaper than the bills given by a private owned hospital. This essay focuses on the benefits of availing the services of government hospitals.

Availing the services of government hospitals is highly beneficial. Apart from the aforementioned cheaper and/or almost free price, government health care also removes discrimination among patients. Discrimination among patients can come in the form of either racial or financial terms. Racial discrimination in hospitals mainly root from medical givers preferring the patients to have the same “blood” in them wherein they have this mindset that they belong to that country due to same ethnicity, beliefs, and color. Racial discrimination rarely applies to hospitals though; however, financial discrimination is another story.

Having trouble obtaining medical care because some filthy-rich businessman managed to get the health benefit before you did, needed to consult a doctor for a check-up but his professional fee and his prescription medicines are so expensive or ever needed a transplant but you were put at the bottom of the list because you cannot pay up? Government health care prevents such financial discrimination by making sure that medical givers treat all patients equally. By making sure that all patients are treated equally, be it they are financially capable or not, the government can ensure quality healthcare for everyone.

Another advantage of Government health care lies in their health care plan regulation. This health care plan runs on making sure that insurance companies abide by their policies. Health insurance companies usually over-charge consumers and even go as far as deny the patient who availed their insurance ample medical coverage for toxic or chronic diseases, make their insurance too expensive for a middle-class patient to afford, rejection due to pre-medical conditions and technologically advanced medical testing. Unfortunately, privately owned insurance health care companies are difficult, even for the government to enforce their rules and regulations in terms of health care insurance. Government regulated health insurance is a different case than a privately owned one since the government will force insurance companies to be held accountable for any medical infractions as well as guaranteeing that health care is provided to everyone.

An ongoing problem on government health care all around the globe is the quality of the health care itself. Government usually solves this problem by gathering, analyzing, and disseminating information. The government also takes into consideration the specialization of doctors that patients with special and critical conditions need. By prioritizing what medical givers should practice and disseminating information regarding the disease and the proper medication and preventions needed, the government not only advertises a safer environment but better quality health care.

Lastly, access to a far more advanced medical technology set-up, patients are able to access first class equipment. While it is true that some private hospitals have the finest medical equipment: from a CT Scan to the sharpest and sturdiest surgical tools, public health care is also given funds by the government in replacing old technologies with new ones which will not only grant patients who can barely afford expensive medication access but will also be of benefit for all since these modern technologies will be able to help in the identification of diseases which may have not been detectable by old practices and old medical equipment.

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Corruption in the health sector: A problem in need of a systems-thinking approach

Health systems are comprised of complex interactions between multiple different actors with differential knowledge and understanding of the subject and system. It is exactly this complexity that makes it particularly vulnerable to corruption, which has a deleterious impact on the functioning of health systems and the health of populations. Consequently, reducing corruption in the health sector is imperative to strengthening health systems and advancing health equity, particularly in low- and middle-income countries (LMICs). Although health sector corruption is a global problem, there are key differences in the forms of and motivations underlying corruption in health systems in LMICs and high-income countries (HICs). Recognizing these differences and understanding the underlying system structures that enable corruption are essential to developing anti-corruption interventions. Consequently, health sector corruption is a problem in need of a systems-thinking approach. Anti-corruption strategies that are devised without this understanding of the system may have unintended consequences that waste limited resources, exacerbate corruption, and/or further weaken health systems. A systems-thinking approach is important to developing and successfully implementing corruption mitigation strategies that result in sustainable improvements in health systems and consequently, the health of populations.

Introduction

The health sector is a dynamic system composed of complex interactions between patients, providers, payers, suppliers, and policy makers. It is exactly this complexity that makes it particularly vulnerable to corruption. Corruption, commonly defined as the “abuse of entrusted power for private gain,” ( 1 ) is a problem within health care systems globally. However, it is important to note that “corruption” not only encompasses actions that are illegal in most countries, but also those that could reasonably be considered unethical, and when pervasive, weaken and foster distrust in the health systems.

Corruption takes many forms within the health sector and occurs at all organizational levels from government agencies to the direct provision of care. Likewise, the motivations underlying health sector corruption vary by country. Therefore, it may be challenging to adapt corruption-mitigating strategies that were successful in one health system to another system with completely different incentives, accountability structures, enforcement mechanisms, and socio-economic and political contexts. Given the heterogeneity and dynamic nature of health systems, sustainable reductions in corruption and resultant improvements in health care delivery require a systems thinking approach.

In order to understand the scope of corruption, its impact on population health and health systems will be reviewed. This will be followed by an overview of common types of health sector corruption with special attention paid to differences in manifestations of and motivation and policies underlying corruption in high-income countries (HICs) and low- and low-middle-income countries (LMICs). The second section will review select anti-corruption strategies that have been implemented in LMICs through systems-thinking lens and how a systems-thinking approach could be utilized to address health sector corruption, particularly in LMICs.

Impact of corruption on population health and health systems

Pervasive corruption has the potential to impact the health of populations. Countries with high levels of corruption spend less on health care as a percentage of gross domestic product ( 2 , 3 ). In addition, high levels of corruption correlate with poor health-related outcomes. This includes higher infant and child mortality rates ( 4 , 5 ), lower life expectancy ( 2 , 5 ), lower immunization rates ( 6 ), and higher rates of antibiotic resistance ( 7 ). Moreover, corruption has a negative effect on the mental health of citizens, with individuals who experience high levels of corruption reporting a lower perception of their overall health ( 8 , 9 ).

Corruption impacts health systems as well. In 2019, the U.S. government recovered $3.6 billion USD in health-related fraud judgements and settlements ( 10 ). However, this likely represents the tip of the iceberg of fraudulent activities in U.S health system, which is estimated to lose $58.5–83.9 billion USD annually to fraud and abuse ( 11 ). This trend is also reflected in global estimates of health care spending, where at least 7% is ceded to corruption, an estimated $500 billion USD ( 12 ). These data suggest that commitment of financial resources may have a diminished impact on the health of populations if they are being diverted for corrupt purposes.

Lastly, corruption is particularly problematic because of who is most affected. Previous studies have shown that corruption impacts the most vulnerable patients regardless of country. Individuals who are in poor health ( 13 ) or are at high socioeconomic risk ( 3 , 14 ) are more likely to make informal payments. Data from sub-Saharan Africa suggests that individuals who reported paying bribes for health-related services were 4 to 9 times more likely to also report difficulty accessing health care ( 15 ). In the United States, nearly 790,000 Medicare beneficiaries over a 3-year period were treated by providers who were subsequently found to have committed fraud and abuse violations ( 16 , 17 ). These beneficiaries were more likely to be non-white, dually eligible for Medicare and Medicaid (suggesting lower income), and disabled ( 16 ).

These examples highlight the deleterious impact of corruption on population health, health systems, and addressing health equity. Consequently, tackling corruption within the health sector is imperative to strengthening health systems. Understanding the forms of health sector corruption is an important first step in these mitigation efforts.

Manifestations of corruption in health systems

In order to understand manifestations of health sector corruption, it is important to be familiar with actors in health systems and their relationships to one another. The exact actors vary from country to country, but roles within health systems can be characterized based on a continuum of service delivery ( Figure 1 ). On one spectrum of health systems, furthest removed from direct provision of services, are governments and the government officials who are responsible for crafting health-related policies, executing the policies, and regulating the health system. At the level of direct service delivery are the health care workers who provide services (e.g., physicians, nurses, pharmacists, etc.), and patients who are the recipients of those services. In between the actors involved in policy and regulation and those involved in the direct provision of care are the payers and suppliers. Payers fund the health system and, depending on the country, may be government agencies, non-profit or for-profit insurance companies, or patients themselves. Suppliers are those that provide the infrastructure and environment for health care to be delivered, e.g., medical device and pharmaceutical companies, equipment manufacturers, etc.) ( 18 ). Importantly, corruption can occur at any level and involve any actor within this complex system. The six forms of health sector corruption reviewed in detail here are improper financial relationships, theft and diversion of resources, fraudulent billing, absenteeism, informal payments, and counterfeit medical supplies (summarized in Table 1 ).

Schematic diagram of actors in the health system along the continuum of service delivery.

Forms of health sector corruption and the actors who are involved.

Improper financial relationships

Improper financial relationships are associations between actors within the health system that have the potential to create a conflict of interest. Specifically, they foster situations where individuals are motivated by financial enrichment over medical indication, patient well-being, and/or public health. At the highest level of service delivery, improper financial relationships can occur between government officials and for-profit entities within the health sector (e.g., pharmaceutical, medical device, insurance companies) ( 19 ). Other potential manifestations of improper relationships at the highest level of government include deregulation of the health sector to the benefit specific interest groups, influence over health-related recommendations or guidelines, expediting approval of pharmaceuticals or medical devices, etc. ( 18 , 20 ).

Improper financial relationships involving providers can also exert inappropriate influence at the level of direct service delivery. Two common business relationships that fall within this category are self-referrals and kickbacks. Self-referrals occur when providers refer patients for medical services performed by an entity with whom the provider or family member has a financial relationship. Although they may be legal, these financial relationships have the potential to result in medically unnecessary interventions or more expensive interventions that financially enrich providers at the expense of patients or payers ( 21 ). Kickbacks at the service-delivery level are similar to those at the government or payer level. For example, a pharmaceutical company may pay inducements to providers to preferentially prescribe their company's medication ( 22 ).

Fraudulent billing and claims

Fraudulent billing refers to the act of obtaining reimbursement for services or items that were either not provided, more complex than what was provided, or medically unnecessary. The actors involved in fraudulent billing can vary depending on how health care was financed. In countries with social health insurance programs, fraudulent billing occurs primarily between providers and either government or private payers. In countries without well-established health insurance systems where out-of-pocket payments predominate, providers may fraudulently obtain reimbursement from patients. In addition, providers may also defraud the government for services or items related to certain diagnoses, patient populations, or conditions that are provided by government at no charge to patients (HIV, tuberculosis, prenatal or pediatric care). Fraudulent billing is a relatively common form of health sector corruption in HICs. In OECD countries, fraudulent billing in the form of overprovision or overbilling for services were among the most common forms of corruption ( 20 , 23 , 24 ).

Theft and diversion

Theft occurs when individuals take resources to which they not entitled without consent or permission. Diversion refers to taking and reselling resources for another purpose without consent or permission. Theft and diversion of resources can occur at all levels of a health system. At the government or payer level, theft often takes the form of embezzlement, where government officials or insurance company employees siphon health-related funding for personal use ( 20 ). In addition, large-scale theft of donor funding allocated to LMICs by government officials has also been reported ( 25 ).

At the provider level, health care workers may divert supplies, medication, equipment, or official fees for financial enrichment ( 26 – 29 ). The extent of theft and diversion at the provider level is challenging to precisely measure. Relative to other forms of corruption, theft and diversion is perceived to be less common in OECD countries ( 20 ). However, qualitative studies from sub-Saharan Africa, indicate that theft may be a larger concern in this region where public health systems have historically been weak ( 26 , 27 ). Health care workers from multiple sub-Saharan African countries report having personal experience with theft within the health system ( 26 – 29 ) and cite low public-sector salaries and suboptimal working conditions as reasons for theft and diversion ( 26 , 27 ).

Absenteeism

Frequent, unauthorized absenteeism is regarded as corrupt when public sector workers “choose to engage in private pursuits during working hours” ( 12 ). Although absenteeism can occur at the highest levels of government, this review will focus on absenteeism of health care workers and its impact on the direct provision of care. Commonly cited factors driving absenteeism include low and/or unreliable salaries in the public sector, lack of monitoring and accountability, and substandard work environments that includes demanding workloads partially induced by frequent absenteeism ( 27 , 28 , 30 – 38 ). Specifically, low and/or unreliable salaries are a major driver of absenteeism. Qualitative studies of absenteeism among public sector health care workers in sub-Saharan Africa illustrate the challenges these individuals face. In Nigeria, public sector health care workers report being unable to cover basic necessities with their salaries, including food, clothing, transportation, etc. ( 39 ). Some of these employees report going 1 year without being paid a salary ( 39 ).

Poor and/or intermittent remuneration promote absenteeism when health care workers engage in dual-practice, or the provision of clinical care in the public and private sector concurrently ( 40 ). Although dual-practice occurs in countries at all income levels ( 40 ), it is particularly problematic for service delivery when health care workers are absent from their public sector position in order to provide care in the private sector ( 27 , 39 , 40 ). In many HICs where governance is stronger, the private sector is formalized, and the health systems are well-developed, dual practice is prohibited or well-regulated and therefore less likely to result in absenteeism ( 40 ). However, many LMICs have weaker governance structures and health systems resulting in a blurred separation of the public and private sector and weak or non-existent regulation of the private sector. These factors contribute to poor regulation of dual practice and incentivizes absenteeism ( 40 ).

Informal payments

Informal payments are defined as “payments to individual and institutional providers, in kind or in cash, that are made outside of official payment channels or are purchases meant to be covered by the health care system” ( 41 ). They can involve actors at all levels of the health care system from government officials, suppliers, and providers. Informal payments can be illegal or legal and encompass a broad range of unofficial exchanges including overt bribes, favors, substantial gifts, and payments solicited under the guise of an official transaction or fee ( 42 ). Some of the motivations underlying informal payments are similar to those described for absenteeism and theft/diversion, namely, low public health salaries ( 43 – 46 ). In addition, cultural and societal norms around gift-giving ( 44 , 46 ), the marketization of health care ( 44 – 46 ), and prevalence of bribery in other sectors of society ( 37 ) are also cited as reasons for informal payments.

Counterfeit medical supplies

Lastly, counterfeit therapeutics, medical devices, and other medical supplies represent an important form of corruption that disproportionately impacts health systems in LMICs ( 47 ). According to a report by the World Health Organization (WHO), 20% of malaria medications, 17% of antibiotics, and 9% of anesthetics/analgesics circulated globally were either substandard or falsified ( 47 ). Although these substandard or falsified products were reported in numerous countries of all income levels, the problem is particularly acute in Africa, which represented 42% of the total reports ( 47 ). Another study evaluating medications in Latin America identified a negative correlation between the quality medications and the level of corruption within the country ( 48 ). It is important to note that while producing and distributing intentionally falsified supplies represents a form of corruption, substandard products may be a result of technical inexperience or weak capacity.

Potential factors giving rise to the circulation of counterfeit medical supplies include poor governance in many LMICs where the regulatory capacity is inadequate to ensure the authenticity of these products ( 47 ). This regulation is further complicated by the fact that many of these supplies are the product of complex multinational supply chains. Regulation may be even more challenging in LMICs without a national insurance program and where patients are paying for these supplies out-of-pocket. Moreover, those who are suspicious of the efficacy of the medication or device may be reluctant to voice their concerns out of fear of reprisal from criminal enterprises involved in trafficking ( 47 ). As highlighted by these examples, while counterfeit medical products occur in countries of all income level, the reporting available suggests the impact is felt most by patients in LMICs.

Corruption in LMICs vs. HICs

The above examples demonstrate that health sector corruption is a global problem with a heterogeneous presentation. For example, fraudulent billing is particularly problematic in countries with some form of social health insurance. In contrast, while theft/diversion, informal payments, absenteeism, and counterfeit medications are present in the health systems of many LMICs, they are less common in HICs. These distinctions highlight the structural differences between health systems in LMICs and HICs, including differing incentives, regulations, policies, forms of remuneration, resources, etc. Moreover, this heterogeneity underscores the need for a systems-thinking approach to address corruption the health sector.

Although corruption occurs in countries of all income levels, this review will focus on using a systems-thinking approach to understand corruption within the health sector in LMICs for two main reasons. The first is that the majority of the most corrupt countries according to Transparency International's Corruption Perceptions Index (CPI) ( 49 ) are categorized as low-income or low-middle income ( 50 ). The second and more relevant reason is that corruption represents an informal institution in many LMICs ( 51 ). As with most institutions, corruption becomes self-reinforcing, fostering an equilibrium of continued corruption that is challenging to disrupt ( 51 ). For this reason, using reductionist strategies to address corruption within health systems of LMICs is unlikely to result in sustainable improvement and may even further exacerbate the problem.

Applying a systems lens to health sector corruption: Structures beneath the surface

The above forms of health sector corruption represent the tip of the iceberg, the events and patterns that are readily visible to observers. However, effectively and sustainably reducing corruption requires an understanding of what is underneath the surface – the structure of health systems, the political and socio-economic environment, and historical context that drive these visible manifestations of corruption ( 52 ). This section will summarize the environmental factors that enable and perpetuate corruption within health systems ( Figure 2 ), with special attention paid to differences in corruption within LMICs and HICs.

Iceberg diagram of health sector corruption.

Socio-economic factors

Although corruption occurs in health sectors of countries at all stages of economic development, the underlying motivations often differ between HICs and LMICs. As outlined in the previous section, absenteeism, informal payments, theft and diversion, and counterfeit medical supplies are forms of health sector corruption that appear to be particularly problematic in LMICs. When evaluating the determinants of these forms of corruption, recurrent patterns that emerge include low and/or unreliable salaries for health care workers and substandard working conditions in the public sector ( 22 , 28 , 30 , 32 , 34 , 38 , 43 – 45 ). When these factors combine with minimal oversight, corrupt individuals in positions of leadership, and corruption in other areas of society ( 22 , 37 , 38 , 53 ) it is unsurprising that corruption represents an institutional reality for health care workers in LMICs rather than a scheme for personal enrichment as is seen in many HICs ( 54 ). These differences in motivations require a different framework for thinking about corruption in LMICs in order to develop effective mitigation strategies.

To explore these important differences in motivating factors that inform the type and scope of corruption, Monika Bauhr puts forth a framework of “need” vs. “greed” corruption ( 54 ). “Need” corruption refers to acts of corruption that are necessary to carry out in order to access services to which citizens are legally entitled. For example, patients are compelled to make informal payments in order to access health care services that should be provided at no or reduced cost by the government. Health care workers have limited choices but to engage in dual practice or to divert supplies or medications in order to supplement unsustainable public sector salaries. In contrast, “greed” corruption refers to acts of corruption that are carried out by actors for the purpose of personal advantage ( 54 ). Embezzlement of health care funds at the government or payer level and some forms of fraudulent billing or improper financial relationships are arguably examples of “greed” corruption.

While greed-based corruption occurs in countries regardless of income level, need-based corruption is relatively uncommon in HICs ( 54 ). Moreover, Bauhr suggests that need-based corruption is associated with lower trust in institutions, an observation that was not seen with greed-based corruption ( 54 ). Given these differences in the trust of institutions and governments, mitigating need-based and greed-based corruption will require different strategies. There is no doubt that corruption occurs in HICs and may even result in larger financial losses. However, in many HICs, there is an institutional and legal framework for investigating corrupt actors and holding them accountable as well as trust among citizens that this will occur. Understanding these motivators is critical to a systems-thinking approach to reduce corruption in the health sector. Although these institutions may exist outside of the health system and well-beneath surface of the metaphorical iceberg, any anti-corruption strategy must understand the institutional context as they influence the personal and work environments of actors within the health system.

Health systems

Another factor beneath the surface of the health sector corruption iceberg is the strength of health systems in LMICs. A significant barrier to improving health outcomes in LMICs are weak health systems ( 55 ). One potential explanation for these weak systems is the wave of structural adjustment programs (SAPs) that were imposed on low-income countries (LICs) by international financial institutions starting in the 1980's ( 56 ). These neoliberal policies required heavily indebted LICs, particularly in sub-Saharan Africa, to reduce public sector spending and enhance privatization and deregulation in exchange for debt reduction ( 57 ). Some have argued that policies enacted in the health sector to comply with SAPs destabilized public health systems; these policies include cuts to public health resources and/or diversion of resources to the private sector, institution of user fees to access health services, and lay-offs or salary reductions of public sector health care workers ( 56 ).

Neoliberal policies represent potential explanation for the weak public health systems that are pervasive in LMICs. These weak systems fail to deliver services to the public and create an environment where the consequences of not engaging in corruption outweigh any potential benefits to holding corrupt actors accountable ( 58 ). This relationship between health sector corruption and weakened health systems is essential to addressing corruption in LMICs and may help to explain why anti-corruption strategies developed in HICs may fail to deliver in LMICs. They also highlight how anti-corruption strategies without concomitant investments in strengthening the health sector, may do little to reduce health sector corruption.

Donors and development aid

When considering how to address health sector corruption in LMICs, it is not only important to understand the context of the health system, but also the socio-economic and political environment in which these health systems exist. One important distinction between the environment within LMICs and HICs, particularly when considering financing of health systems, is the role of donors and development aid. From 1990 to 2014, nearly $460 billion USD in development aid was disbursed from high-income to developing countries ( 59 ). Donor funding is estimated to represent 30% of health care expenditures in low-income countries (LICs) ( 12 ). This proportion is even higher for HIV-, malaria-, and tuberculosis-related care where donor funding of these disease entities is over two times the amount spent by ministries of health ( 12 ).

Although investments in the health sector made possible through development aid has saved countless lives, it is important to understand the role of donors within health systems and health sector corruption as development aid continues to be allocated to corrupt countries ( 60 , 61 ). In sub-Saharan Africa specifically, aid as a percentage of GDP and government expenditure are negatively correlated with quality of governance, even after controlling for GDP per capita ( 62 ). Specific to the health sector, approximately $34 million USD of development aid was diverted from the Global Fund ( 25 ), leading to significant changes in policies related to transparency and accountability ( 63 ). However, it remains to be seen whether these strategies are effective in addressing corruption ( 63 ). Therefore, the presence of donors and donor funding adds another layer of complexity to health systems in LMICs. Systems thinking can be utilized to better understand the role of development aid and its interactions with other variables that contribute to health sector corruption.

Applying a systems lens to health sector corruption: Effectiveness of anti-corruption strategies

The evidence indicates that corruption is problem that must be addressed to strengthen the health systems of LMICs. Goals of modern anticorruption strategies include strengthening accountability, detection, and enforcement; improving transparency; and preventing corruption through provision of resources. Examples of strategies utilized to achieve each of these goals are outlined in Table 2 . Unfortunately, there is a dearth of strong evidence supporting the efficacy of anti-corruption reforms in the health sector and strongest evidence was for programs implemented in HICs ( 64 ). Given the significant differences between health systems in HICs and LMICs highlighted above, it is unclear whether these strategies can be adapted in other settings with the same success. Moreover, many anti-corruption strategies address individual interactions or behaviors, but do not explore how those interactions fit within the context of the system. This section summarizes the effectiveness of three strategies that have been utilized in LMICs to reduce corruption: anti-corruption agencies to strengthen accountability and enforcement, community engagement to improve transparency, and raising public sector salaries to prevent corrupt behavior through provision of resources. These strategies will be reviewed in a systems-thinking context to highlight the limitations of viewing corruption within the health system as isolated linear relationships.

Examples anti-corruption theories and corresponding strategies.

Anti-corruption agencies

In the systematic review cited above, the study that provided the strongest indication of success was a series of legislative and executive efforts in the U.S. aimed at curbing fraud and abuse in Medicare and Medicaid ( 64 ). These efforts included formation of an anti-corruption task force with prosecutorial authority and upgrading the analytic capacity for improved detection of billing irregularities ( 64 ). As a result of increased detection of fraudulent activities and resultant convictions, the anti-corruption task force was estimated to have recovered $1–3 billion USD per year over the course of 10 years ( 64 ).

Formation of independent anti-corruption agencies has also been attempted in LMICs, but with mixed results. For example, in Karnatka, India, an anti-corruption agency underwent a change in scope and leadership in 2001 to address rampant public sector corruption. Under new leadership, this agency uncovered systemic corruption within the health sector partly through an increase in citizen reporting. However, there was no concomitant increase in convictions for corrupt acts as a result of this improved detection. One reason for this lack of enforcement was the weak political support for this agency's activities, limiting its ability to investigate and prosecute the corrupt behavior it uncovered, particularly at higher levels of the government ( 65 ).

In contrast to the experience in Karnatka, an anti-corruption agency in Uganda was granted substantial enforcement authority and was formed by the president himself in response to pervasive health sector corruption ( 66 ). This agency was responsible for a significant decline in bribery among health care workers, the recovery of millions in USD worth of stolen health supplies, and the conviction of health care workers for corruption-related crimes. However, without a simultaneous effort to raise salaries and improve working conditions, health care worker morale deteriorated under the agencies aggressive tactics resulting in a prolonged strike that that debilitated the nation's health system ( 66 ).

These examples highlight the danger of applying a reductionist, rather than a systems-thinking approach. Forming an anti-corruption agency addresses a component of the system – individual acts of corruption among service providers. However, they do little to address the working conditions, institutional and economic factors, and social norms that enable individuals to ask for a bribe or divert medical supplies. At a minimum, the status quo remains in effect if there is no political backing of the agency or ability to enforce anti-corruption regulation, as highlighted by the example in Karnatka. At their worst, they can result in significant unintended consequences that further weaken the health system, as highlighted by the example in Uganda. Although allocating resources to enhance detection and enforcement has the potential to reduce individual corrupt actions in the short-term, these tactics may only represent a “quick fix.” Over time, aggressive enforcement of corruption in isolation can decrease health care worker morale resulting in increased number of health care workers leaving the public sector. This would have the unintended and delayed consequence of further weakening the health system ( Figure 3A ).

Causal loop diagrams for the following anti-corruption strategies. (A) Anti-corruption agency, (B) community engagement, and (C) raising salaries.

Community engagement

Another strategy used to reduce corruption is mobilizing community members to hold actors in the health system accountable through enhanced transparency. For example, the presence of a monitoring board composed of community members in Bolivia was associated with a decrease in informal payments and overpricing for supplies and medications ( 67 ). A randomized control trial in Uganda demonstrated that health care service delivery and population health indicators improved when citizens were provided performance metrics on their health facilities and encouraged to engage with health care workers to develop a shared action plan to improve local health outcomes ( 68 ). Lastly, formalized citizen feedback can catalyze and inform anti-corruption efforts. Information from social audit surveys that polled perceptions of and experiences with corruption in Nicaragua were used to lobby for anti-corruption policies and ethics training for public officials ( 69 ).

Similar to anti-corruption agencies, it is unclear if community engagement as an isolated strategy is sufficient to curb entrenched health sector corruption. For instance, a randomized trial evaluating the effectiveness of a community-based transparency campaign in Tanzania and Indonesia failed to improve health outcomes in the intervention communities ( 70 ). In this study, citizens were invited to attend meetings with a facilitator to discuss their experiences with and develop a set of activities to address maternal and newborn health in their community. However, there were no resources or support provided by the program outside of these facilitated meetings. At the conclusion of the study, there was no significant improvement in the use of perinatal and postnatal services, birth weight, or feelings of civic engagement between the intervention and control groups. The authors speculate that it was challenging for participants to operationalize the ideas developed during the facilitated discussions into actions that would lead to tangible improvements ( 70 ).

In fact, methods commonly used to engage community members through increased transparency could have the unintended consequence of leading to more corruption. At least two studies have shown that exposing citizens to anti-corruption media actually increased their willingness to pay a bribe ( 71 , 72 ). The content of the media varied in each study, but included messaging on the pervasiveness of corruption ( 72 ), recent corruption scandals, the impact of corruption on communities, and recent anti-corruption efforts undertaken by the government ( 71 ). It is possible that anti-corruption media campaigns may perpetuate feelings futility and powerlessness among community members, rather than mobilizing them to combat corruption ( 71 ).

These examples address one component of the system – public awareness of corruption. The long-term goal of these awareness building campaigns is to hold those in position of power accountable. However, if enhanced transparency is not coupled with legitimate and visible efforts by health care workers to improve services or government to commit resources to improve the health system or deliver on anti-corruption policies, then advertising the extent of corruption may only perpetuate the perception that corruption is pervasive and inevitable ( Figure 3B ). This can create a reinforcing loop where citizens believe that corruption is ubiquitous and therefore they engage in corruption. The ultimate result is even more corruption that becomes increasingly institutionalized within the system.

Raising salaries

Lastly, investing resources in health systems of LMICs, specifically to improve wages of health care workers in the public sector, may itself represent an anti-corruption strategy. Despite increased spending on health care globally over the past 2 decades, there are significant disparities in per capita spending between in HICs ($5,252 USD) and LMICs ($40–81 USD) ( 73 ). This disparity in funding may underly the aforementioned pattern seen in LMICs of health care workers engaging in corruption to supplement unsustainably low public sector salaries. Consequently, it is plausible that health care workers may be less likely to engage in dual practice, solicit informal payments, and/or divert supplies and medications to supplement their income if they are paid an sufficient and reliable salary. Adequate investments in health sector infrastructure, equipment, and guarantee of supply chains for therapeutics and consumable supplies can improve access to services, which could also deter perpetuation of an unregulated private sector within health systems of LMICs ( 74 ).

Ecological studies incorporating data from numerous countries across multiple continents indicates that, specifically in LMICs, there is an association between higher civil servant salaries and lower corruption ( 75 , 76 ). However, based on modeling from one of these studies, salaries would need to be increased substantially to eliminate corruption if raising wages was the only strategy used (i.e., in the absence of concomitant enforcement mechanisms to deter corruption) ( 76 ). Moreover, on an individual country level, the suggestion that higher salaries alone will reduce corruption is less clear. In 2010, the Ghanaian government doubled police officer salaries, in part to reduce corruption within the police force. However, efforts to solicit bribes and the monetary value of bribes paid to police officers actually increased after 2010, suggesting the higher salaries exacerbated corruption ( 77 ). The authors offered potential reasons for this unexpected result. First, raising salaries may have contributed to a sense of entitlement among police officer to expect higher bribes. Also, the higher income may have created additional pressures to financially support extended family members that necessitated the solicitation of more bribes ( 77 ).

Although not specific to the health sector, this example highlight the complicated nature of corruption. Supplementing low salaries may be one reason for engaging in corruption, but there are important social and institutional factors that also contributed to a police officer's willingness to solicit a bribe. These other factors may not be readily apparent without utilizing a systems-thinking approach. In this example, raising wages without interventions that address other aspects of the system, such as a concomitant effort to enhance detection and enforcement of corrupt activities or change the institutional culture away from bribe-taking, may actually act as reinforcing feedback that amplifies corruption. In the case of a health system, implementation of strategies targeted only one aspect of the system may not only by exacerbate corruption, but also by direct significant resources to a solution that is ultimately ineffective at achieving the intended goal ( Figure 3C ).

Applying systems-thinking tools to address health sector corruption

As previously discussed, health systems are comprised of complex interactions between numerous actors. These systems are extremely heterogeneous in terms of structure, funding, incentives, resource allocation, etc. Furthermore, there are key differences in the socio-economic and political environments within LMICs and HICs that impact health systems within these countries, including the role of donors and development aid. Consequently, adapting an anti-corruption strategy that was developed in HICs to a health system in LMICs may do little to improve the system or result in unintended consequences that exacerbate corruption or further weaken the health system. These challenges of adaptation are highlighted by the aforementioned example of implementing an anti-corruption agency. For these reasons, corruption in the health sector, specifically within LMICs, is a problem in need of a systems-thinking approach.

Systems thinking has been previously applied to understand corruption in LMICs outside of the health sector ( 78 , 79 ). These previously employed strategies can be combined with a health system strengthening framework put forth by de Savigny et al. ( 80 ) to better understand and disrupt health sector corruption. We propose a 4-part process to apply systems thinking to health sector corruption: qualitative analysis, developing a system map, designing an intervention, and developing an evaluation framework.

Qualitative analysis

A qualitative analysis is an essential first step to a complete understanding of health sector corruption. Some have argued that corruption is particularly intractable because it serves a function in the system ( 78 ). Consequently, interventions that disrupt this function will be met with resistance. Based on studies cited above, the function of practices such as absenteeism, theft/diversion, and informal payments within the health sector of LMICs may include access to faster services or supplementing low salaries. However, given the heterogeneity of health systems globally, a local understanding is required to fully appreciate the role corruption plays in a given system.

A key component to this local understanding is getting input from actors at all levels of health sector, including those in positions of leadership ( Figure 1 ). This qualitative input should focus on the informants' perceptions of, personal experiences with, and motivations underlying corruption in the health sector. Informants should also be asked about their impression of the health system more broadly, including their understanding of the incentives, configuration of leadership, regulations, renumeration structures, accountability structures, etc.

Analysis of this qualitative data can then be organized into themes that provide stakeholders with a better understanding of health sector corruption. As an example, qualitative analysis was performed by Scharbatke-Church et al. ( 81 ) to better understand corruption within the criminal justice system in Northern Uganda. Through this analysis, they identified several functions of corruption, including access to police or judges, maintaining power, or to generate revenue for operating costs to the maintain the system. Applying a similar strategy to the health sector has the potential to not only reveal to types of corruption that are occurring and the actors involved, but more importantly, its functions and the key dynamic relationships that enable corruption and maintain its role in the health system. Moreover, this deep understanding of the system will prevent inappropriate adaptation of anti-corruption programs that were utilized elsewhere.

System mapping

The understanding of the system gained from the qualitative analysis can then be used to develop a causal loop diagram. The goal of the causal loop diagram is to visually represent the complex relationships between variables within the system that contribute to corruption ( 81 ). This approach was used in in Pakistan where Ullah et al. ( 79 ) conducted a thorough qualitative analysis focusing on citizens' experience with, perceptions of, and strategies for combatting corruption. Based on the themes extracted from this analysis, they created a comprehensive causal loop diagram modeling corruption in Pakistan that was inclusive of social, economic, legal, and political relationships. Through this process the authors identified several variables contributing to corruption that were under recognized in literature, such as the role of inflation, religious values, the size of government, and transparency in development aid. In Northern Uganda, a system map of the criminal justice system was essential to identifying both the drivers and enablers of corruption and the function that corruption serves in the system. This information was critical because most of the existing anti-corruption strategies in this region were only addressing enablers, not drivers, of corruption ( 78 ).

In the setting of health sector corruption, variables contributing to corruption may include suboptimal work conditions; low salaries for public sector workers; long wait times for services; scarcity of medications and/or medical supplies; lack of monitoring and accountability of health care workers, industry, suppliers, donor agencies, and policy makers; knowledge asymmetry between actors; corrupt behavior modeled by those in leadership positions; etc. After all the variables have been identified, one can use causal links to illustrate the dynamic relationships between variables. This system map complete with variables and causal links can help stakeholders identify reinforcing loops that exacerbate corruption or stabilizing loops that promote an equilibrium of corrupt behavior that becomes institutionalized within the health system. A potential example of how corruption can become institutionalized is the experience of public health care workers in rural Uganda who negotiated changes to facility workflow in order to accommodate for baseline staffing shortages due to pervasive absenteeism ( 53 ).

Furthermore, an understanding of these dynamic relationships is critical to anticipate temporal delays between and downstream effects of a precipitating factor and the ultimate outcome. Combatting corruption in the health sector is a long-term endeavor, understanding where delayed results could occur will prevent stakeholders or funders from prematurely abandoning an effective strategy where evidence of success may not be readily apparent. This comprehensive representation of the system is essential to designing an effective intervention.

Designing (and refining) an intervention

After a health system and the impact of corruption on the system has been sufficiently mapped, an intervention can be developed. Using the format proposed by de Savigny et al. ( 80 )designing an intervention starts with getting input from key stakeholders who represent different levels of the system and are positioned to understand areas that need to be improved. In the case of reducing health sector corruption in LMICs, these key stakeholders may include government officials and other policy-makers, donors, development organizations, payers, suppliers, providers, and patients. An ideal intervention should utilize a combination of measures that address different variables within the system ( 82 ). As highlighted by the anti-corruption strategies mentioned in previous sections, targeting one component of the system is unlikely to bring sustainable change. For instance, only addressing incentive structures by raising salaries without a concomitant effort to bolster monitoring and enforcement may perpetuate and even exacerbate corruption as seen in the example from Ghana ( 77 ).

Any potential intervention should then be applied to the system map to assess its effect on existing feedback loops, anticipate unintended consequences, and identify delayed outcomes. System dynamics modeling is one approach to this assessment. System dynamics modeling is an iterative process that utilizes mathematical modeling to predict the impact of various hypothetical scenarios on a given system ( 83 ). Information from these models can be used to further refine the intervention to mitigate negative downstream effects or unintended consequences.

Developing an evaluation framework

Once an intervention has been designed and refined based on the system map, then an evaluation framework can be developed. However, there are some important features of corruption that must be considered when creating an evaluation strategy. First, the illicit nature of corruption makes it challenging to identify indicators of progress that can be reliably measured ( 84 ). Moreover, there is no clearly defined “road map” for successfully mitigating corruption in the health sector ( 64 ) and therefore typical monitoring and evaluation approaches for public health programs may not apply in this setting. Lastly, it will be challenging to anticipate every potential impact an intervention may have on systems as dynamic and resistant to change as health sector corruption in LMICs. For these reasons, evaluating the progress of anti-corruption strategies requires a non-traditional approach.

An example of such an approach has been previously described for a collective action intervention to reduce corruption in the criminal justice system of the DRC ( 84 ). Although a thorough systems analysis was performed at the outset, the authors describe a frequent monitoring and evaluation process characterized by an openness to challenge this initial analysis and make changes based on feedback collected after implementation of the intervention. Importantly, this feedback came from program participants rather than implementers ( 84 ). This example demonstrates that an iterative evaluation framework based on feedback from patients, providers, suppliers, and policy-makers may be preferable to a rigid evaluation plan with pre-defined indicators for success for addressing health sector corruption. In addition, frequent evaluation in the context of the system map should be included to make any changes to the intervention if necessary.

Health care delivery results from an intricate series of interactions between numerous different actors within the system. It is clear that pervasive corruption is a detriment to effective health care delivery, particularly in LMICs. Addressing health sector corruption has the potential to strengthen health systems where they have historically been weak. However, due to the complexity and heterogeneity of health systems globally, a comprehensive understanding of the system structures that underly the individual instances and patterns of corrupt behavior is essential to developing an effective anti-corruption strategy. Anti-corruption strategies developed without this understanding are unlikely to result in meaningful improvements and may even further weaken health systems. Consequently, health sector corruption in LMICs is a problem in need of a system-thinking approach in order develop and successfully implement mitigation strategies that result in sustainable improvements in health systems and consequently, the health of populations.

Author contributions

EG performed the literature review, applied the systems-thinking conceptual framework to corruption, and wrote the article.

Conflict of interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The author would like to acknowledge Taryn Vian, Professor of Public Health at the University of San Francisco for her mentorship, guidance, and contributions to this manuscript.

30 Best universities for Mechanical Engineering in Moscow, Russia

Updated: February 29, 2024

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• Engineering
• Environmental Science
• Liberal Arts & Social Sciences
• Mathematics

Below is a list of best universities in Moscow ranked based on their research performance in Mechanical Engineering. A graph of 269K citations received by 45.8K academic papers made by 30 universities in Moscow was used to calculate publications' ratings, which then were adjusted for release dates and added to final scores.

We don't distinguish between undergraduate and graduate programs nor do we adjust for current majors offered. You can find information about granted degrees on a university page but always double-check with the university website.

1. Moscow State University

For Mechanical Engineering

2. Bauman Moscow State Technical University

3. National Research University Higher School of Economics

4. Moscow Aviation Institute

5. N.R.U. Moscow Power Engineering Institute

6. National Research Nuclear University MEPI

7. National University of Science and Technology "MISIS"

8. Moscow Institute of Physics and Technology

9. Moscow State Technological University "Stankin"

10. RUDN University

11. Moscow Polytech

12. Moscow State University of Railway Engineering

13. Finance Academy under the Government of the Russian Federation

14. Moscow Medical Academy

15. Russian State University of Oil and Gas

16. mendeleev university of chemical technology of russia.

17. Russian National Research Medical University

18. Plekhanov Russian University of Economics

19. National Research University of Electronic Technology

20. Moscow State Pedagogical University

21. Russian Presidential Academy of National Economy and Public Administration

22. State University of Management

23. Moscow State Institute of International Relations

24. Russian State Geological Prospecting University

25. russian state agricultural university.

26. New Economic School

27. Moscow State Technical University of Civil Aviation

28. Russian State University for the Humanities

29. Russian State Social University

30. Moscow State Linguistic University

Universities for Mechanical Engineering near Moscow

Engineering subfields in moscow.

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