[Dual practice in the Spanish health system: problem or solution? SESPAS Report 2024]. / La práctica dual público-privada en la sanidad española. ¿Solución o problema? Informe SESPAS 2024.

The Spanish public health system is overburdened. As a result, heath care professionals are showing symptoms of burnout, while private health services are expanding more than ever. As revealed by numerous strikes in recent years, health care professionals want better pay and work conditions and feel frustrated by their inability to give proper time and care to their patients. The institutional response from regional governments in Spain has been to remove the exclusivity clause that provided a salary bonus for physicians who worked entirely in the public sector; now all physicians receive this bonus, effectively promoting dual (public and private) practice. Although dual practice may increase the income of physicians and other health professionals, it poses several challenges that are analyzed in this paper. We also discuss alternative and more far-reaching policies that we believe should be implemented by the government in order to deal with the current crisis of the health system.

Identifying early adopters of COVID-19 vaccines in Latin America.

COVID-19 vaccine hesitancy is currently-one of the main obstacles to worldwide herd immunity and socioeconomic recovery. Because vaccine coverage can vary between and within countries, it is important to identify sources of variation so that policies can be tailored to different population groups. In this paper, we analyze the results from a survey designed and implemented in order to identify early adopters and laggers in six big cities located in Argentina, Colombia, Chile, Ecuador, Peru, and Dominican Republic. We find that trust in government and science, accurate knowledge about the value of vaccination and vaccine effects, and perceived risk of getting sick is associated with a higher probability to get vaccinated. We also identify potential laggers such as women and populations with high education but low knowledge about vaccines. We discuss specific strategies to promote vaccination among these populations groups as well as more general strategies designed to gain trust. These findings are specific to the context of Latin America insofar as the underlying factors associated with the choice to be vaccinated vary significantly by location and in relation to individual-level factors.

Lockdown strictness and mental health effects among older populations in Europe.

This paper investigates whether lockdown policies aggravated mental health problems of older populations (50 and over) in Europe during the first COVID-19 wave. Using data from the Survey of Health, Ageing and Retirement in Europe (SHARE COVID-19 questionnaire) and from the Oxford COVID-19 Government Response Tracker for 17 countries, we estimate the causal effect of lockdown policies on mental health by combining cross-country variability in the strictness of the policies with cross-individual variability in face-to-face contacts prior to the pandemic. We find that lockdown policies worsened insomnia, anxiety, and depression by 5, 7.2 and 5.1 percentage points, respectively. This effect was stronger for women and those aged between 50 and 65. Interestingly, lockdown policies notably damaged the mental health of healthy populations. We close with a discussion of lockdown policies targeted at individuals above 65 and/or with pre-existing conditions.

Using visual stimuli to promote healthy snack choices among children.

Most interventions against obesity use information to persuade people to change their behavior, with moderate results. Because eating involves automatic routines, new approaches have emerged appealing to non-reflective cognitive processes. Through a randomized controlled trial, we evaluated the impact of visual stimuli (positive and negative) on children's snack-choices at school. Results showed that the negative stimulus had no effect, while the positive stimulus increased the probability among girls of choosing a healthy snack. We also found that children with excess weight had a larger baseline probability of choosing the healthy snack than those without. We conclude that happy emojis, used to nudge non-reflective processes, can steer children towards healthy choices.

Risk attitudes in medical decisions for others: An experimental approach.

The aim of this paper is to investigate how risk attitudes in medical decisions for others vary across health contexts. A lab experiment was designed to elicit the risk attitudes of 257 medical and nonmedical students by assigning them the role of a physician who must decide between treatments for patients. An interval regression model was used to estimate individual coefficients of relative risk aversion, and an estimation model was used to test for the effect of type of medical decision and experimental design characteristics on elicited risk aversion. We find that (a) risk attitudes vary across different health contexts, but risk aversion prevails in all of them; (b) students enrolled in health-related degrees show a higher degree of risk aversion; and (c) real rewards for third parties (patients) make subjects less risk-averse. The results underline the importance of accounting for attitudes towards risk in medical decision making.

Cost sharing and hospitalizations for ambulatory care sensitive conditions.

During the last decade, Chile's private health sector has experienced a dramatic increase in hospitalization rates, growing at four times the rate of ambulatory visits. Such evolution has raised concern among policy-makers. We studied the effect of ambulatory and hospital co-insurance rates on hospitalizations for ambulatory care sensitive conditions (ACSC) among individuals with private insurance in Chile. We used a large administrative dataset of private insurance claims for the period 2007-8 and a final sample of 2,792,662 individuals to estimate a structural model of two equations. The first equation was for ambulatory visits and the second for future hospitalizations for ACSC. We estimated the system by Two Stage Least Squares (2SLS) corrected by heteroskedasticity via Generalized Method of Moments (GMM) estimation. Results show that increased ambulatory visits reduced the probability of future hospitalizations, and increased ambulatory co-insurance decreased ambulatory visits for the adult population (19-65 years-old). Both findings indicate the need to reduce ambulatory co-insurance as a way to reduce hospitalizations for ACSC. Results also showed that increasing hospital co-insurance does have a statistically significant reduction on hospitalizations for the adult group, while it does not seem to have a significant effect on hospitalizations for the children (1-18 years-old) group. This paper's contribution is twofold: first, it shows how the level of co-insurance can be a determinant in avoiding unnecessary hospitalizations for certain conditions; second, it highlights the relevance for policy-making of using data on ACSC to improve the efficiency of health systems by promoting ambulatory care as well as population health.

Maternity waiting homes and institutional birth in Nicaragua: policy options and strategic implications.

With the aim of promoting institutional births and reducing the high maternal and child mortality rates in rural and poor zones, the government of Nicaragua is supporting the creation of maternity waiting homes. This study analyzes that strategy and examines the factors associated with the use of maternity waiting homes and institutional birth. To that end, we apply a quantitative approach, by means of an econometric analysis of the data extracted from surveys conducted in 2006 on a sample of women and parteras or traditional birth attendants, as well as a qualitative approach based on interviews with key informants. Results indicate that although the operation of the maternity waiting homes is usually satisfactory, there is still room for improvement along the following lines: (i) disseminating information about the homes to both women and men, as the latter frequently decide the course of women's healthcare, and to parteras, who can play an important role in referring women; (ii) strengthening the postpartum care; (iii) ensuring financial sustainability by obtaining regular financial support from the government to complement contributions from the community; and (iv) strengthening the local management and involvement of the regional government. These measures might be useful for health policy makers in Nicaragua and in other developing countries that are considering this strategy.

Whom do physicians work for? An analysis of dual practice in the health sector.

This article presents a thorough analysis of dual practice among physicians who work in both the public and private sectors. A conceptual framework is presented to help the reader understand dual practice and the contexts where it takes place. The article reviews the existing theoretical and empirical literature on this form of dual practice among physicians. It analyzes the extent of this phenomenon, the underlying factors that motivate physicians to engage in dual practice, and the main implications of their decision to do so. It also examines and discusses current policies that address dual practice. In this regard, the article provides some qualified support for the use of "rewarding" policies to retain physicians in the public sectors of more developed countries, while "limiting" policies are recommended for developing countries - with the caveat that the policies should be accompanied by the strengthening of institutional and contracting environments. The article highlights the lack of quality evaluative evidence regarding the consequences of dual practice on the delivery of health care services. It concludes that the overall impact of dual practice remains an open question that warrants more attention from researchers and policy makers alike.

Policy and regulatory responses to dual practice in the health sector.

Physician dual practice is a widespread phenomenon which has implications for the equity, efficiency and quality of health care provision. Central to the analysis of physician dual practice is the trade-off between its benefits and costs, as well as the convenience of regulating it to undermine its adverse consequences. In this paper, we study and analyze different governmental responses to this activity. We find that internationally, there are wide variations in how governments tackle this issue. While some governments fully prohibit this practice, others regulate or restrict dual job holding with different intensities and regulatory instruments. The measures implemented include limiting the income physicians can earn through dual job holding, offering work benefits to physicians in exchange for their working exclusively in the public sector, raising public salaries, and allowing physicians to perform private practice at public facilities. We present the pros and cons of each of these alternatives and show how the health care market and institutional arrangements are crucial for the design and implementation of each of these strategies. The paper also identifies the need for empirical evidence on the effect of different government strategies on dual practice.

Accounting for quality in the measurement of hospital performance: evidence from Costa Rica.

This paper provides insights into how Costa Rican public hospitals responded to the pressure for increased efficiency and quality introduced by the reforms carried out over the period 1997-2001. To that purpose we compute a generalized output distance function by means of non-parametric mathematical programming to construct a productivity index, which accounts for productivity changes while controlling for quality of care. Our results show an improvement in hospital performance mainly driven by quality increases. The adoption of management contracts seems to have contributed to such enhancement, more notably for small hospitals. Further, productivity growth is primarily due to technical and scale efficiency change rather than technological change. A number of policy implications are drawn from these results.

The impact of hospital management reforms on absenteeism in Costa Rica.

The reduction of high levels of absenteeism among health care workers was one the objectives of the reforms undertaken to improve public hospital performance during the 1990s in Costa Rica. This paper attempts to assess the impact of changes in reimbursement methods and organizational reform on absence rates among health care personnel in Costa Rican public hospitals for the period 1995-2001. Our results show the reforms to have had a negative impact on absenteeism, which increased throughout the considered period. Results further indicate that the policy of not substituting absentee workers, which was introduced through the reforms, did not work as expected in a permissive environment in which peer pressure mechanisms were lacking. In addition, the explicit incentives for workers included in the reforms were retained and used at facility level. There is a pressing need in the future for control and disciplinary mechanisms for health care personnel and for the introduction of absence rates as an explicit goal to be monitored and evaluated.