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Keywords:

  • responsiveness;
  • patient-centred care;
  • medicalization;
  • outpatient care;
  • cost;
  • simulated patients;
  • prescribing;
  • public–private;
  • consumer protection

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Background and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Objective  To document differences in provider behaviour between private and public providers in hospital outpatient departments, health centres and clinics in Bangkok, Thailand.

Method  Analysis of the characteristics of 211 taped consultations with simulated patients.

Results  Private hospitals and clinics were significantly more responsive. Private clinics but not private hospitals were also significantly more patient-centred. All doctors, but particularly those in private hospitals, prescribed unnecessary and potentially harmful technical investigations and drugs. The direct cost to the patient varied between 1.5 (in public health centres) and 12 (in private hospitals) times the minimum daily wage. The combined cost – to the patient and to the state – in public hospitals and health centres exceeded the cost of consultations in private clinics.

Conclusion  Market incentives favour responsiveness and a patient-centred approach, but not more appropriate therapeutic decisions. Excessive use of pharmaceuticals is observed among public as well as private providers, but is most pronounced in private hospitals. If patients in Bangkok want to maximize responsiveness and degree of patient-centred care and yet minimize costs and iatrogenesis, they would benefit from avoiding hospitals, both public and private, and, to a lesser extent, specialists. Choosing to use primary facilities, health centres and clinics, particularly when consultations are carried out by general practitioners (GPs), is more beneficial than choosing between public and private providers.

Objectif  Documenter les différences de comportement chez les praticiens entre secteur privé et public, dans les services de patients ambulants des hôpitaux, des centres de santé et des cliniques de Bangkok, Thaïlande.

Méthode  Analyse des caractéristiques de 211 consultations enregistrées avec des patients simulés.

Résultats  Les hôpitaux et cliniques privés répondaient de façon plus significative. Les cliniques privées mais pas les hôpitaux privés, avaient une approche plus centrée sur le patient. Tous les médecins et en particulier ceux des hôpitaux privés, prescrivaient des examinations techniques et des médicaments non nécessaires et potentiellement dangereux. Le coût directe pour le patient variait entre 1.5 (dans les centres de santé publique) et 12 (dans les hôpitaux privés) fois le revenu minimal journalier. Le coût combiné, pour le patient et l’état, dans les hôpitaux publics et les centres de santé dèpassait le coût des consultations dans les cliniques privées.

Conclusion  Les incitations du marché favorisent la réponse et l'approche centrée sur le patient, mais pas plus de décisions thérapeutiques appropriées. L'utilisation excessive de médicaments est observée autant chez les praticiens du secteur public que du secteur privé. Mais, elle est plus accentuée dans les hôpitaux privés. Si les patients à Bangkok veulent maximiser la réponse et le degré d'approche centrée sur le patient en minimisant les coûts et les effets iatrogènes, ils bénéficieraient en évitant autant les hôpitaux publics que privés et, dans une moindre mesure les spécialistes. Choisir l'utilisation des secteurs de soin primaire, des centres de santé et des cliniques - en particulier lorsque les consultations sont menées par un médecin généraliste - est plus bénéfique que choisir entre dispensateurs publics et privés.

Mots clés  Réponse, approche centrée sur le patient, médication, de patients ambulants, coût, patients simulés, prescription, public–privé, protection des consommateurs

Objetivo  Documentar las diferencias en comportamiento del proveedor entre hospitales privados y públicos en consultas externas, centros de salud y clínicas en Bangkok, Tailandia.

Método  Análisis de las características de 211 consultas grabadas con pacientes simulados.

Resultados  Los hospitales privados y las clínicas tuvieron una respuesta significativamente mejor. Las clínicas privadas, mas no los hospitales privados, también tenían una mayor dedicación al paciente. Todos los médicos, pero particularmente aquellos de hospitales privados, prescribieron medicamentos innecesarios así como técnicas o medicamentos bajo investigación potencialmente peligrosos. El coste directo al paciente variaba entre 1.5 (en centros de salud públicos) y 12 (en hospitales privados) veces la salario diario mínimo. El costo combinado – al paciente y al estado – en hospitales públicos y centros de salud excedió el costo de las consultas en clínicas privadas.

Conclusión  Los incentivos del mercado favorecen el interés y la dedicación al paciente, pero no la toma de decisiones terapéuticas apropiadas. Se observó un uso excesivo de fármacos tanto el los hospitales públicos como privados, pero de forma más pronunciada en los hospitales privados. Si los pacientes de Bangkok desean maximizar el interés y el grado de dedicación en la atención y además minimizar los costos y la iatrogenia, deberían evitar los hospitales, tanto públicos como privados, y en menor extensión a los especialistas. Escoger el usar servicios primarios, centros de salud y clínicas, particularmente cuando las consultas son realizadas por médicos generales, es más benéfico que escoger entre proveedores públicos y privados.

Palabras clave  interés, dedicación en el cuidado del paciente, medicación, consultas externas, pacientes simulados, prescripción, publico-privado, protección al consumidor


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Background and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Given the opportunity and the means, many patients in developing countries – as well as in the industrialized world – prefer private practitioners to the public sector, particularly for primary care (Mulou et al. 1992; Brown & Lumley 1993; Ellis et al. 1994; Ahmed et al. 1996; Tangcharoensathien et al. 1999; Tengilimoglu et al. 1999). Patients expect more responsiveness and/or a better quality of care – a difference that many feel is worth paying for. Micro-economic theory supports this: there are more incentives for private providers, particularly in outpatient settings, to pay attention to perceived quality, and, consequently, to responsiveness and patient-centred care. These expected advantages are said to justify the prominence of market incentives in many of the health care reforms proposed in developing countries. There is, however, surprisingly little empirical evidence – aside from a small number of patient satisfaction surveys – to back up the assumptions about the comparative advantages of private health care delivery (Brown & Lumley 1993; Yedidia 1994; Laslett et al. 1997; Camilleri & O'Callaghan 1998; Tangcharoensathien et al. 1999; Tengilimoglu et al. 1999; Andaleeb 2000; Ferrinho et al. 2001). Furthermore, the notions of private and public can encompass different ways of providing care: through hospitals or primary care level facilities, by general practitioners (GPs) or specialists.

We examined whether private facilities actually fulfil these patient expectations in Bangkok, Thailand – that is, whether patients get value for money when they choose private providers for primary health care. Instead of relying on patient satisfaction surveys we used simulated patients with a standardized set of symptoms and questions to allow a direct observation of provider behaviour. This made it possible to compare the responsiveness, the degree of patient-centred approach, the appropriateness of therapeutic decisions and the cost of outpatient consultations in public and private hospitals, health centres and clinics.

Background and methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Background and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Thai patients can freely choose their doctor in the public or the private sector; they can choose to see a specialist or a GP, in hospitals, health centres or clinics. In Bangkok, public sector doctors provide outpatient care either in the outpatient department (OPD) of the public sector hospitals, or, more rarely, in health centres. Most also provide ambulatory care, in their ‘after hours’ private clinics. They do this on the basis of reputation they acquire in their hospitals as specialists or as GPs. GPs merely are non-specialists rather than ‘family practitioners’. They are not expected to demonstrate the specific skills associated with the modern notion of ‘family practitioner’, as understood by e.g., the World Organisation of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA).

As many other mega cities in the south, Bangkok has witnessed a major development of a policy-controlled, private, for-profit health care sector. Two types of private practices can be distinguished: clinics and hospitals. Private clinics are small entrepreneurial units providing outpatient care. Most are owned by government doctors who work after official hours, and are located in urban areas. Private hospitals provide both in-and outpatient care. There has been a boom of for-profit private hospitals since the end of the 1980s, encouraged by a corporate tax and customs duty exemption for private hospital construction. The rationale for encouraging the development of private hospitals was the idea that competition and market would improve quality. Doctors eagerly supported this move in a way to fulfil their income expectations.

This study was conducted in a random sample of consultations in four settings: public health centres, public hospitals, private clinics and private hospitals. In each category, facilities were chosen at random, as were the doctors in the facilities.

After appropriate training, six simulated patients (three males and three females, averaging 25 years of age, to avoid gender bias) were asked to attend consultations with standardized complaints of anxiety, presenting as recurring stomach ache which responds well to self-administered antacids. The current episode was said to have started 4 days previously. The ‘patients’ were instructed to indicate that the problem had actually started 4 months earlier when the patient's mother suffered a stroke. They had to appear anxious, to express a fear of cancer, and to request information and explanation through agreed cue questions and statements. This particular complaint was choosen because it is common, typical for the somatization of psychosocial problems, and because confronted with such a complaint doctors should pay particular attention to being patient-centred.

Training and pre-testing, as well as the subsequent analysis of the encounters, showed no differences in performance between the six ‘patients’. They consulted a total of 211 doctors: 63 specialists and 57 GPs in private clinics and hospital OPDs, and 26 specialists and 65 GPs in public health centres or hospital OPDs. The high proportion of specialists in private and public OPD facilities reflects the fact that the private sector focuses more on specialist services than the public sector. In each setting, 57–62% of the doctors were male. The doctors were not informed that they were seeing simulated patients. Assignment of patients to doctors was random. Each ‘patient’ saw between 34 and 37 doctors.

Consultations were taped with a concealed recorder, and the simulated patients took structured notes immediately after the consultation. The material was transcribed and handed over to the investigators after eliminating all clues to the doctor's identity. Approval of the research protocol and of the confidentiality procedures was obtained from the ethical committee of the Ministry of Public Health, Thailand, and the Klum Sampran Committee.

The different settings were compared with regard to the following dimensions: responsiveness, degree of patient-centred approach, appropriateness of the therapeutic response and cost. The degree of responsiveness was analyzed by looking at opening hours, waiting time, consultation time (component parts being: physical examination, talking to the patient, and time allowed for patients to express their problems), requests for follow-up visits, and use of the politeness particles khrap and kaa (a characteristic of the Thai language) by the doctor. The degree of patient-centredness was measured by scoring responses to requests for information, empathy and anxiety relief (Henbest & Fehrsen 1992). Responses to requests for information were assessed by scoring the answers to ‘What is this illness?’ Responses to requests for empathy with the patient's predicament were assessed by scoring the answers to ‘I am under a lot of stress, I have to care for my mother who had a stroke, how can I handle all this?’ Responses to requests for anxiety relief were assessed by scoring the doctors’ reactions to two questions: (i) ‘Why does this happen to me? Is this a cancer like my uncle had 4 years ago?’ and (ii) ‘Will I die?’ The cue questions were short, in order to increase the probability that patients would be able to use them within the consultation time.

Scoring of the transcribed tape-recordings used the following scale: ‘0’: there was no opportunity to express the cue question or hint; (1): the doctor ignored or cut the question short; (2): the doctor responded in a closed fashion, e.g. Q: ‘Why does this happen to me?’ A: ‘This can happen to everybody (followed by change of subject)’; (3): the patient was allowed to elaborate and (4): the patient was encouraged to elaborate and express expectations or feelings. This gives a possible range of 0–16: 0–8 for anxiety relief, 0–4 for information giving, and 0–4 for empathy. Scoring was performed blindly, i.e., without information on where the consultation took place (clinic, health centre, hospital, public or private) or on whether the doctor was a specialist or a GP.

Inter-rater reproducibility of the scoring was assessed by comparing the assigned scores with scores of an independent scorer not involved in the research on 168 questions from 42 of 211 consultations (systematic 1/5 sample). The scores disagreed on 3 of 168 items.

The appropriateness of the therapeutic responses of in the various settings was compared by looking at the number and types of drugs prescribed and the further investigations suggested by the doctor.

The direct costs to the patient were calculated from the consultation fees and the costs of the drugs prescribed (in Thailand these costs are often combined into a single fee). The simulated patients obviously did not undergo the complementary examinations suggested by the doctors, but it was simple to cost them at the current market rate. Suggested follow-up consultations were not costed.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Background and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Responsiveness

Thai private practitioners conduct consultations at a time of the day that is a priori convenient to their clients and are accessible outside ‘normal’ working hours. In contrast, this was only the case for 33% of public facilities in our sample. Total waiting time was considerably longer in public facilities: an average of 81 min (median 76) as opposed to an average of 20 min (median 14) in private clinics or hospitals (Figure 1). Waiting was longer at all stages: at reception, between reception and consultation, at the cashier following the consultation and to obtain any prescribed medications. Waiting times were much longer in hospitals than in clinics or health centres (Mann–Whitney U test: P < 0.001), and slightly longer for specialists than for GPs (M–W U: P < 0.001). However, average waiting times were always much longer in the public sector.

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Figure 1. Median waiting times at the reception, before consultation, at the cashier and in obtaining drugs, for private and public outpatients.

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Private doctors were found to be more polite, as evidenced by the more frequent use of the politeness particles ‘khrap’ and ‘kaa’. Doctors in public facilities tended to be more abrupt. One typical exchange in a public facility was the following, recorded as the patient came into the consultation room: Dr: ‘What is the matter?’ Patient: ‘Good morning doctor (politeness particle)’. Dr: ‘Good morning. What is the matter? (no politeness particle)’ Exchanges such as this were rarely recorded at private consultations.

On average, consultations with private doctors lasted 6.2 min, with public doctors only 3.8 (M–W U: P < 0.001). The differences remain when one looks at the consultation components’ median durations in the different kinds of facilities, as in Figure 2. Private doctors did a perfunctory physical examination; in public facilities the average time for examining patients was only 4 s. Most of the private–public difference in duration of the consultation was accounted for by conversation. The median time private doctors talked to their patients was 2 min 34 s as opposed to 1 min 17 s for doctors in public facilities (M–W U: P < 0.001). Patients also had more time to express themselves in private settings (67 s) than in the public sector consultations (50 s).

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Figure 2. Median consultation time in private and public settings, disaggregated for the time patients are allowed to express their problem, the time allocated to physical examination, the time the doctor himself is talking to the patient, and the time the doctor spends writing or dealing with the nursing and administrative staff.

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Patients were asked to return for a follow-up visit in 63% of private and 39% of public hospitals. In health centres and private clinics this was less frequent (23% and 21%, respectively). Requests for follow-up visits were often related to recommendations for further technical investigations.

Degree of patient-centredness

Figure 3 shows the average scores, in the different settings, for the responses to the requests for information, empathy and anxiety relief. The ‘patients’ found it challenging to field all four sets of cue questions or statements. They succeeded in doing so only in 39.6% of consultations with public and in 65.3% with private doctors. When patients were able to express the cue question or request, most often the doctor either did not react at all (score 1) or answered with a statement that excluded further elaboration (score 2). For example, an answer to ‘Why is this happening to me?’ could be ‘It's not only you, everyone can have the same disease as yours (change of subject)’, or an answer to ‘Will I die?’ in one case, was ‘Everyone dies, nobody knows when (change of subject)’.

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Figure 3. Average patient-centred care scores in different public and private settings. The total patient-centred care score (out of a maximum of 16) is the sum of the scores for response to requests for information, for empathy and for anxiety relief.

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Open answers (scored 3) or encouragement of the patient to express expectations or feelings (score 4) were rare. Only 1.1% of public and 7.5% of private doctors reached a total patient-centred care score of 10 or more out of a maximum of 16. There were no relevant or significant differences according to the gender of either doctor or patient.

The median score for degree of patient-centred care in consultations with private doctors was 5.4/16; in public settings it was 4.2/16 (M–W U: P < 0.01). In each of the three patient-centred care dimensions (empathy, information and anxiety relief) private clinics scored highest (Figure 3).

Therapeutic decisions

With the type of complaints presented by the simulated patients, anxiety relief through counselling, or self-treatment with antacids, would be the treatments of choice. None of the 211 doctors chose these options. Those seen in public facilities were prescribed an average of 2.8 drugs per patient and those seen privately, 3.8 drugs. Along with an average of 1.6 antacids per patient, doctors prescribed 0.6 GI regulators and 0.6 antispasmodics. 24% of public and 59% of private doctors prescribed tranquilizers. Some private doctors also prescribed antibiotics or antidepressants; 5% of private doctors recommended unknown drugs to be administered by injection.

Almost half of the private and one-third of the public sector doctors recommended endoscopy and/or a barium meal investigation. Figure 4 shows that this occured with greater frequency in hospitals than in health centres and clinics and more often in consultations with specialists than with GPs. In private hospitals, GPs recommended these investigations to 55% of patients (and in one case also a stomach biopsy), specialists to 68%. Private clinics, on the other hand, did not ask for more technical investigations than doctors in public health centres.

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Figure 4. Proportion of patients to whom the doctor recommended technical investigations in different private and public settings.

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Cost

Patients were exempt from paying consultation fees in public hospitals and health centres. The average private hospital charged a consultation fee of $US 3.8. Drug charges were highest in private hospitals ($US 9.9) and lowest in public health centres ($US 1.4). In private clinics the consultation fee was included in the fee paid for medications, as is customary in Thailand.

A significant part of the total cost to the patient resulted from the recommended additional technical investigations. The cost of the suggested investigations was highest in private hospitals (average $US 31.6), and lowest in private clinics run by GPs (average $US 3.6).

The total cost to the patient i.e., consultation fee if charged, drug costs, and cost of recommended investigations was highest in private hospitals (average $US 45.7), and lowest for consultations with GPs in private clinics (average $US 11.1) and in health centres (average $US 5.7) (Figure 5). This corresponds to between 1.5 and 12 times Thailand's minimum daily wage of $US 3.7.

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Figure 5. Average direct costs to the patient (consultation fees, drugs and recommended investigations) and estimated costs to the State of a medical outpatient consultation in the different settings. Note that in private clinics consultation fees are included in the drug charges.

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The estimated unit cost to the State of an outpatient consultation in a public sector facility ranges from $US 5.3–6.6 (Lertiendumrong 2001). This cost is not carried over to the patient. Adding the cost to the State to the cost borne by the patient puts the total average cost of a consultation in the public sector between $US 11 and 24.3. The average total cost of a consultation in the public facilities was higher than that of a consultation in private clinics.

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Background and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Statements on the comparative advantages of publicly and privately provided health care largely rely on theoretical and ideological extrapolations from the expected consequences of financial incentives, asymmetry of information and conflicts of interest between provider and user. Empirical information is hard to come by, especially on outpatient care.

Patient satisfaction surveys usually show that patients are more satisfied with both out-and in-patient private care (Brown & Lumley 1993; Yedidia 1994; Laslett et al. 1997; Camilleri & O'Callaghan 1998; Tangcharoensathien et al. 1999; Tengilimoglu et al. 1999) although there are instances, including in Thailand, where this pattern is actually reversed for inpatient care (Ahmed et al. 1996; Tangcharoensathien et al. 1999). Patient satisfaction may be an important factor for the patient's future choices of provider, but it is only one of the dimensions of quality of care, and one that is likely to be biased because of the asymmetry of information. Also it reflects the degree of satisfaction with regard to the patient's individual expectations rather than the latent concept of actual qualities of the interaction.

Indicators such as total consultation time, have been suggested as proxies for quality of care (Howie et al. 2000) and could be used for comparison – of hospital outpatient vs. primary care facilities, or, of public vs. private providers. They are, however, no substitute for direct observation. Direct observation of consultation is obviously subject to bias. One way to limit bias in the observation of consultations is to use simulated patients. Simulated patients have been used before, for studies of drug shops, pharmacies, family planning services or to look at how doctors and nurses prescribe drugs (Madden et al. 1997). The use of simulated patients in this study made it possible to provide first-hand direct information on various aspects of outpatient care with minimal observation bias. Standardized case histories and cue questions, in combination with blinded analysis of the consultation tapes and transcripts, allowed for a standardized and reproducible comparison of the various settings. The type of complaint chosen requires empathy, communication and patient-centredness from the first contact, rather than a strictly biomedical reaction which might have been appropriate for other presenting symptoms. To our knowledge this study provides the first comparison of private and public outpatient care based on the observation of a range of attributes covering aspects of responsiveness, degree of patient-centred approach, therapeutic decisions and cost.

Our results confirm the micro-economic prediction that private practitioners have an incentive to be responsive. In the public sector waiting times are considerably longer, doctors are more abrupt, consultation times are shorter and during consultation hours that are less likely to be convenient to the patient. Such indicators of responsiveness are known to be associated with patient satisfaction (Dye & Wojtowycz 1999; Tokunaga et al. 2000) and, as far as consultation time is concerned, with quality of care (Howie et al. 1989,1991,1997,1998,1999,2000).

In terms of patient-centredness the public–private differences have to be qualified. Consultations by private practitioners were significantly more patient-centred than those in public facilities. This was mainly the case in private clinics where the scores were twice as high as in the public sector. The difference in patient-centred care was much less pronounced in private hospitals. The greater degree of patient-centredness in the private sector is most likely the result of the economic incentives to provide patient friendliness, which is what one would expect for private providers who work on a fee-for-service basis. At least in part it is also closely related to the greater length of the consultations and particularly of the fact that patients receive a greater opportunity to express themselves. With half a minute for this, as in public facilities, a patient-centred approach must be nearly impossible. There is not much more time in consultations with private practitioners, but even small differences in time for patients to express themselves apparently make a difference. A patient-centred approach is obviously related to responsiveness, but there is more to it than just that. It goes to the core of an effective consultation (Henbest & Fehrsen 1992), especially for the kind of complaints presented by the simulated patients in this study (Roter et al. 1997). In this sense, the degree of patient-centred approach is directly relevant to quality of care in these consultations.

Although there are public–private differences in patient-centred care, very few doctors, be they public or private, got high scores. All services left a lot to be desired in terms of patient-centred care. Few showed propensity or capacity for listening. Patients were most often not helped to express their concerns or not even given the opportunity to do so, although they did have more time to offer hints in the longer private consultations. Answers were usually closed and stereotyped. The complaints apparently triggered a categorization by the doctors (private and public alike) in terms of ‘gastritis stress-eating behaviour.’ Doctors started explaining this nosological interpretation to the patient very early in the consultation, at the expense of listening. Since in Thai culture patients have to pay respectful attention to what the doctor says, cue questions could often only be asked at the end of consultation. By that time the opportunity for interaction was lost as doctors were seeking to end the consultation. This pattern was the same in both public and private settings. It is consistent with the observation that the time allowed for patients to speak was related to the patient-centred care score, whereas the time the doctor spent talking to their patients was not.

Doctors showed little more propensity or capacity for counselling. Many seem to have recognized anxiety and fear as a key feature of their patient's history. They did not, however, respond with information, reassurance or counselling. Rather, they relied on tranquilizers or recommendations for endoscopy or barium meal investigation.

One would expect doctors in the public sector to be more concerned with rational and parsimonious prescribing than private doctors. This was indeed the case, and the drug bills of private doctors were at least double of those in public facilities. Nevertheless, all doctors, including those in public facilities, wrote potentially iatrogenic prescriptions of a multitude of inappropriate drugs. Doctors in private hospitals were not only the ones to prescribe most drugs, they also asked for most follow-up investigations: the technology is available and there is a financial incentive to make use of it. In public hospitals, however, the financial incentives are less relevant, but doctors also recommended expensive complementary investigations in one-third of consultations. This was considerably more than in both public health centres and private clinics, suggesting that the bio-technological bias of the professional environment is an important reason for over-prescription by itself, and only enhanced by the perverse financial incentives in private hospitals. In health centres and clinics, where the technology was not directly available and when there was little to be gained from recommending such investigations, patients were less likely to get complementary investigations. The possibility of being prescribed such examinations was lowest in public health centres run by GPs. In both public and private settings the total cost of prescribed drugs and recommended investigations was slightly higher for doctors whose patient-centredness scores were in the bottom quartile (respectively 13.7 and 29.6 US$) than for those in the top quartile (respectively 12.3 and 29.6 US$).

In many developing countries, particularly in urban areas, health care is reduced to its bio-technological dimension. Doctors in Bangkok are no exception, be they private practitioners or working in the public sector. Apart from the resulting lack of patient-centred care, ineffectiveness and iatrogenesis this has major consequences for the cost of health care to the patients.

The direct cost to the patient is higher in hospitals than in a primary care setting, higher for a specialist consultation than with a GP, and higher in the private than in the public sector. Private hospitals are significantly more expensive than all the other facilities. However, if one takes into account the government subsidies to the public facilities, private clinics surprisingly come out as having the lowest service costs. Much of this due to the investigations prescribed during consultation in public facilities.

Thai patients are correct in their expectations of private facilities, which show a great degree of responsiveness and of patient-centred care, though at a price in terms of money and potential ill effects from unnecessary prescriptions. The comparative advantage of private facilities, however, must be qualified. If patients wish to receive a service which includes the highest levels of responsiveness and patient-centred care, and minimize costs and iatrogenesis, it would be advisable to avoid hospitals, public or private, and to a lesser extent specialists. By choosing a primary care provider i.e., a health centre or clinic, where they are attended by a GP, they are more likely to receive a service fulfiling their expectations, rather than choosing between a public or private provider. Primary care facilities prescribe fewer unnecessary drugs and technical examinations. They do so at the lowest direct cost for the patient, and, in the case of the private clinics, in the most responsive and patient-centred manner, among the different providers of ambulatory care in Bangkok.

The first – and most important – choice patients have to make in Bangkok is what level of health care they will use. The choice between private or public provider comes second. The behaviour of physicians in public and private hospitals suggests that incentives for primary care gate keeping (such as better pay, better training and more realistic workload) and a more appropriate medical culture are priorities to improve the quality of care patients receive. The information gained from the direct observation of doctors in their day-to-day practice shows the importance of organizing some form of consumer protection in medical systems where provider behaviour is largely unregulated.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Background and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

We are grateful to Dr. Banpot Pinitchan for his assistance with the quality control of the scoring and to Ms. Supattra Toviriyavej and Ms Jiraporn Chanpeng for their help in organising the field operations, and Dr Megan Crofts for reviewing the manuscript. This research was made possible by a grant from the EC funded Health Care Reform project (ALA/94/28), contract nr 107.

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  1. Top of page
  2. Summary
  3. Introduction
  4. Background and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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