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Tropical Medicine and International Health doi:10.1111/j.1365-3156.2005.01532.

volume 11 no 1 pp 8189 january 2006

Choosing between public and private or between hospital


and primary care: responsiveness, patient-centredness and
prescribing patterns in outpatient consultations in Bangkok
Yongyuth Pongsupap1 and Wim Van Lerberghe2

1 National Health Security Office, Nonthaburi, Thailand


2 World Health Organization, Geneva, Switzerland

Summary 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.

keywords responsiveness, patient-centred care, medicalization, outpatient care, cost, simulated patients,
prescribing, publicprivate, consumer protection

small number of patient satisfaction surveys to back up


Introduction
the assumptions about the comparative advantages of
Given the opportunity and the means, many patients in private health care delivery (Brown & Lumley 1993;
developing countries as well as in the industrialized Yedidia 1994; Laslett et al. 1997; Camilleri & OCal-
world prefer private practitioners to the public sector, laghan 1998; Tangcharoensathien et al. 1999; Tengili-
particularly for primary care (Mulou et al. 1992; Brown & moglu et al. 1999; Andaleeb 2000; Ferrinho et al. 2001).
Lumley 1993; Ellis et al. 1994; Ahmed et al. 1996; Furthermore, the notions of private and public can
Tangcharoensathien et al. 1999; Tengilimoglu et al. 1999). encompass different ways of providing care: through
Patients expect more responsiveness and/or a better quality hospitals or primary care level facilities, by general
of care a difference that many feel is worth paying for. practitioners (GPs) or specialists.
Micro-economic theory supports this: there are more We examined whether private facilities actually fulfil
incentives for private providers, particularly in outpatient these patient expectations in Bangkok, Thailand that is,
settings, to pay attention to perceived quality, and, whether patients get value for money when they choose
consequently, to responsiveness and patient-centred care. private providers for primary health care. Instead of relying
These expected advantages are said to justify the promin- on patient satisfaction surveys we used simulated patients
ence of market incentives in many of the health care with a standardized set of symptoms and questions to
reforms proposed in developing countries. There is, how- allow a direct observation of provider behaviour. This
ever, surprisingly little empirical evidence aside from a made it possible to compare the responsiveness, the degree

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Y. Pongsupap & W. Van Lerberghe Choosing between public and private or between hospital and primary care

of patient-centred approach, the appropriateness of thera- and statements. This particular complaint was choosen
peutic decisions and the cost of outpatient consultations in because it is common, typical for the somatization of
public and private hospitals, health centres and clinics. psychosocial problems, and because confronted with such
a complaint doctors should pay particular attention to
being patient-centred.
Background and methods
Training and pre-testing, as well as the subsequent
Thai patients can freely choose their doctor in the public or analysis of the encounters, showed no differences in
the private sector; they can choose to see a specialist or a performance between the six patients. They consulted a
GP, in hospitals, health centres or clinics. In Bangkok, total of 211 doctors: 63 specialists and 57 GPs in private
public sector doctors provide outpatient care either in the clinics and hospital OPDs, and 26 specialists and 65 GPs in
outpatient department (OPD) of the public sector hospi- public health centres or hospital OPDs. The high propor-
tals, or, more rarely, in health centres. Most also provide tion of specialists in private and public OPD facilities
ambulatory care, in their after hours private clinics. They reflects the fact that the private sector focuses more on
do this on the basis of reputation they acquire in their specialist services than the public sector. In each setting,
hospitals as specialists or as GPs. GPs merely are non- 5762% of the doctors were male. The doctors were not
specialists rather than family practitioners. They are not informed that they were seeing simulated patients.
expected to demonstrate the specific skills associated with Assignment of patients to doctors was random. Each
the modern notion of family practitioner, as understood patient saw between 34 and 37 doctors.
by e.g., the World Organisation of National Colleges, Consultations were taped with a concealed recorder, and
Academies and Academic Associations of General Practi- the simulated patients took structured notes immediately
tioners/Family Physicians (WONCA). after the consultation. The material was transcribed and
As many other mega cities in the south, Bangkok has handed over to the investigators after eliminating all clues
witnessed a major development of a policy-controlled, to the doctors identity. Approval of the research protocol
private, for-profit health care sector. Two types of private and of the confidentiality procedures was obtained from
practices can be distinguished: clinics and hospitals. Private the ethical committee of the Ministry of Public Health,
clinics are small entrepreneurial units providing outpatient Thailand, and the Klum Sampran Committee.
care. Most are owned by government doctors who work The different settings were compared with regard to the
after official hours, and are located in urban areas. Private following dimensions: responsiveness, degree of patient-
hospitals provide both in-and outpatient care. There has centred approach, appropriateness of the therapeutic
been a boom of for-profit private hospitals since the end of response and cost. The degree of responsiveness was
the 1980s, encouraged by a corporate tax and customs analyzed by looking at opening hours, waiting time,
duty exemption for private hospital construction. The consultation time (component parts being: physical exam-
rationale for encouraging the development of private ination, talking to the patient, and time allowed for
hospitals was the idea that competition and market would patients to express their problems), requests for follow-up
improve quality. Doctors eagerly supported this move in a visits, and use of the politeness particles khrap and kaa (a
way to fulfil their income expectations. characteristic of the Thai language) by the doctor. The
This study was conducted in a random sample of degree of patient-centredness was measured by scoring
consultations in four settings: public health centres, public responses to requests for information, empathy and anxiety
hospitals, private clinics and private hospitals. In each relief (Henbest & Fehrsen 1992). Responses to requests for
category, facilities were chosen at random, as were the information were assessed by scoring the answers to What
doctors in the facilities. is this illness? Responses to requests for empathy with the
After appropriate training, six simulated patients (three patients predicament were assessed by scoring the answers
males and three females, averaging 25 years of age, to to I am under a lot of stress, I have to care for my mother
avoid gender bias) were asked to attend consultations with who had a stroke, how can I handle all this? Responses to
standardized complaints of anxiety, presenting as recurring requests for anxiety relief were assessed by scoring the
stomach ache which responds well to self-administered doctors reactions to two questions: (i) Why does this
antacids. The current episode was said to have started happen to me? Is this a cancer like my uncle had 4 years
4 days previously. The patients were instructed to indi- ago? and (ii) Will I die? The cue questions were short, in
cate that the problem had actually started 4 months earlier order to increase the probability that patients would be
when the patients mother suffered a stroke. They had to able to use them within the consultation time.
appear anxious, to express a fear of cancer, and to request Scoring of the transcribed tape-recordings used the
information and explanation through agreed cue questions following scale: 0: there was no opportunity to express

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Y. Pongsupap & W. Van Lerberghe Choosing between public and private or between hospital and primary care

the cue question or hint; (1): the doctor ignored or cut the facility was the following, recorded as the patient came
question short; (2): the doctor responded in a closed into the consultation room: Dr: What is the matter?
fashion, e.g. Q: Why does this happen to me? A: This can Patient: Good morning doctor (politeness particle). Dr:
happen to everybody (followed by change of subject); (3): Good morning. What is the matter? (no politeness
the patient was allowed to elaborate and (4): the patient particle) Exchanges such as this were rarely recorded at
was encouraged to elaborate and express expectations or private consultations.
feelings. This gives a possible range of 016: 08 for On average, consultations with private doctors lasted
anxiety relief, 04 for information giving, and 04 for 6.2 min, with public doctors only 3.8 (MW U:
empathy. Scoring was performed blindly, i.e., without P < 0.001). The differences remain when one looks at the
information on where the consultation took place (clinic, consultation components median durations in the different
health centre, hospital, public or private) or on whether the kinds of facilities, as in Figure 2. Private doctors did a
doctor was a specialist or a GP. perfunctory physical examination; in public facilities the
Inter-rater reproducibility of the scoring was assessed by average time for examining patients was only 4 s. Most of
comparing the assigned scores with scores of an inde- the privatepublic difference in duration of the consulta-
pendent scorer not involved in the research on 168 tion was accounted for by conversation. The median time
questions from 42 of 211 consultations (systematic 1/5 private doctors talked to their patients was 2 min 34 s as
sample). The scores disagreed on 3 of 168 items. opposed to 1 min 17 s for doctors in public facilities (M
The appropriateness of the therapeutic responses of in W U: P < 0.001). Patients also had more time to express
the various settings was compared by looking at the themselves in private settings (67 s) than in the public
number and types of drugs prescribed and the further sector consultations (50 s).
investigations suggested by the doctor. Patients were asked to return for a follow-up visit in
The direct costs to the patient were calculated from the 63% of private and 39% of public hospitals. In health
consultation fees and the costs of the drugs prescribed (in centres and private clinics this was less frequent (23% and
Thailand these costs are often combined into a single fee). 21%, respectively). Requests for follow-up visits were
The simulated patients obviously did not undergo the often related to recommendations for further technical
complementary examinations suggested by the doctors, but investigations.
it was simple to cost them at the current market rate.
Suggested follow-up consultations were not costed.
Degree of patient-centredness
Figure 3 shows the average scores, in the different settings,
Results for the responses to the requests for information, empathy
and anxiety relief. The patients found it challenging to
Responsiveness
field all four sets of cue questions or statements. They
Thai private practitioners conduct consultations at a time succeeded in doing so only in 39.6% of consultations with
of the day that is a priori convenient to their clients and are public and in 65.3% with private doctors. When patients
accessible outside normal working hours. In contrast, this were able to express the cue question or request, most often
was only the case for 33% of public facilities in our sample. the doctor either did not react at all (score 1) or answered
Total waiting time was considerably longer in public with a statement that excluded further elaboration (score
facilities: an average of 81 min (median 76) as opposed to 2). For example, an answer to Why is this happening to
an average of 20 min (median 14) in private clinics or me? could be Its not only you, everyone can have the
hospitals (Figure 1). Waiting was longer at all stages: at same disease as yours (change of subject), or an answer to
reception, between reception and consultation, at the Will I die? in one case, was Everyone dies, nobody knows
cashier following the consultation and to obtain any when (change of subject).
prescribed medications. Waiting times were much longer in Open answers (scored 3) or encouragement of the patient
hospitals than in clinics or health centres (MannWhitney to express expectations or feelings (score 4) were rare. Only
U test: P < 0.001), and slightly longer for specialists than 1.1% of public and 7.5% of private doctors reached a total
for GPs (MW U: P < 0.001). However, average waiting patient-centred care score of 10 or more out of a maximum
times were always much longer in the public sector. of 16. There were no relevant or significant differences
Private doctors were found to be more polite, as according to the gender of either doctor or patient.
evidenced by the more frequent use of the politeness The median score for degree of patient-centred care in
particles khrap and kaa. Doctors in public facilities consultations with private doctors was 5.4/16; in public
tended to be more abrupt. One typical exchange in a public settings it was 4.2/16 (MW U: P < 0.01). In each of the

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Y. Pongsupap & W. Van Lerberghe Choosing between public and private or between hospital and primary care

90 Waiting time: pharmacist


Waiting time: cashier
80 Waiting time: before consultation
Waiting time: receptionist
70

60
Time (min)

50

40

30

20

10
Figure 1 Median waiting times at the
0 reception, before consultation, at the cash-
Public Health Public Health Public Hospital Public Hospital, Private Clinic, Private Clinic, Private Hospital,Private Hospital,
Centre, GP Centre, GP Specialist GP Specialist GP Specialist
ier and in obtaining drugs, for private and
Specialist public outpatients.

8 Other
Physical examination
Doctor talks
7
Patient talks

5
Time (min)

3
Figure 2 Median consultation time in pri-
2 vate and public settings, disaggregated for
the time patients are allowed to express
1 their problem, the time allocated to physical
examination, the time the doctor himself is
0 talking to the patient, and the time the
Public Health Public HealthPublic Hospital Public Private Clinic, Private Clinic, Private Private
Centre, GP Centre, GP Hospital, GP Specialist Hospital, GP Hospital, doctor spends writing or dealing with the
Specialist Specialist Specialist nursing and administrative staff.

three patient-centred care dimensions (empathy, informa- private doctors recommended unknown drugs to be
tion and anxiety relief) private clinics scored highest administered by injection.
(Figure 3). 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
Therapeutic decisions
greater frequency in hospitals than in health centres and
With the type of complaints presented by the simulated clinics and more often in consultations with specialists than
patients, anxiety relief through counselling, or self- with GPs. In private hospitals, GPs recommended these
treatment with antacids, would be the treatments of investigations to 55% of patients (and in one case also a
choice. None of the 211 doctors chose these options. stomach biopsy), specialists to 68%. Private clinics, on the
Those seen in public facilities were prescribed an average other hand, did not ask for more technical investigations
of 2.8 drugs per patient and those seen privately, 3.8 than doctors in public health centres.
drugs. Along with an average of 1.6 antacids per patient,
doctors prescribed 0.6 GI regulators and 0.6
Cost
antispasmodics. 24% of public and 59% of private
doctors prescribed tranquilizers. Some private doctors Patients were exempt from paying consultation fees in
also prescribed antibiotics or antidepressants; 5% of public hospitals and health centres. The average private

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Y. Pongsupap & W. Van Lerberghe Choosing between public and private or between hospital and primary care

7 Score for anxiety relief (max 8)

Patient centredness score (maximum 16)


Score for empathy (max 4)
Score for information (max 4)
6

2
Figure 3 Average patient-centred care
scores in different public and private set- 1
tings. The total patient-centred care score
(out of a maximum of 16) is the sum of the 0
Public Health Public Health Public Hospital, Public Hospital, Private Cliinic, Private Clinic, Private Hospital, Private Hospital,
scores for response to requests for infor- Centre, GP Centre, GP Specialist GP Specialist GP Specialist
mation, for empathy and for anxiety relief. Specialist

80
% of patients to whom the doctor recommended

Biopsy
Both gastroscopy and X-ray
70 X-ray
Gastroscopy

60

50
investigations

40

30

20

10
Figure 4 Proportion of patients to whom
the doctor recommended technical investi- 0
Public Health Public Health Public Public Private Clinic, Private clinic, Private Private
gations in different private and public Centre, GP Centre, Hospital, GP Hospital, GP Specialist Hospital, GP Hospital,
settings. Specialist Specialist Specialist

hospital charged a consultation fee of $US 3.8. Drug The estimated unit cost to the State of an outpatient
charges were highest in private hospitals ($US 9.9) and consultation in a public sector facility ranges from $US
lowest in public health centres ($US 1.4). In private clinics 5.36.6 (Lertiendumrong 2001). This cost is not carried
the consultation fee was included in the fee paid for over to the patient. Adding the cost to the State to the cost
medications, as is customary in Thailand. borne by the patient puts the total average cost of a
A significant part of the total cost to the patient resulted consultation in the public sector between $US 11 and 24.3.
from the recommended additional technical investigations. The average total cost of a consultation in the public
The cost of the suggested investigations was highest in facilities was higher than that of a consultation in private
private hospitals (average $US 31.6), and lowest in private clinics.
clinics run by GPs (average $US 3.6).
The total cost to the patient i.e., consultation fee if
Discussion
charged, drug costs, and cost of recommended investiga-
tions was highest in private hospitals (average $US 45.7), Statements on the comparative advantages of publicly and
and lowest for consultations with GPs in private clinics privately provided health care largely rely on theoretical
(average $US 11.1) and in health centres (average $US 5.7) and ideological extrapolations from the expected conse-
(Figure 5). This corresponds to between 1.5 and 12 times quences of financial incentives, asymmetry of information
Thailands minimum daily wage of $US 3.7. and conflicts of interest between provider and user.

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Y. Pongsupap & W. Van Lerberghe Choosing between public and private or between hospital and primary care

60 Cost to the State


Cost of investigations as recommended
Cost of drugs as prescribed
Consultation fee
50

40
Cost ($US)

30

20
Figure 5 Average direct costs to the
10 patient (consultation fees, drugs and
recommended investigations) and estimated
costs to the State of a medical outpatient
0 consultation in the different settings. Note
Public Health Public Health Public Hospital, Public Hospital, Private clinic, Private clinic, Private Private
Centre, GP Centre, GP Specialist GP Specialist Hospital, GP Hospital, that in private clinics consultation fees are
Specialist Specialist included in the drug charges.

Empirical information is hard to come by, especially on dardized and reproducible comparison of the various
outpatient care. settings. The type of complaint chosen requires empathy,
Patient satisfaction surveys usually show that patients communication and patient-centredness from the first
are more satisfied with both out-and in-patient private care contact, rather than a strictly biomedical reaction which
(Brown & Lumley 1993; Yedidia 1994; Laslett et al. 1997; might have been appropriate for other presenting symp-
Camilleri & OCallaghan 1998; Tangcharoensathien et al. toms. To our knowledge this study provides the first
1999; Tengilimoglu et al. 1999) although there are comparison of private and public outpatient care based
instances, including in Thailand, where this pattern is on the observation of a range of attributes covering
actually reversed for inpatient care (Ahmed et al. 1996; aspects of responsiveness, degree of patient-centred
Tangcharoensathien et al. 1999). Patient satisfaction may approach, therapeutic decisions and cost.
be an important factor for the patients future choices of Our results confirm the micro-economic prediction that
provider, but it is only one of the dimensions of quality of private practitioners have an incentive to be responsive. In
care, and one that is likely to be biased because of the the public sector waiting times are considerably longer,
asymmetry of information. Also it reflects the degree of doctors are more abrupt, consultation times are shorter
satisfaction with regard to the patients individual expec- and during consultation hours that are less likely to be
tations rather than the latent concept of actual qualities of convenient to the patient. Such indicators of responsiveness
the interaction. are known to be associated with patient satisfaction (Dye
Indicators such as total consultation time, have been & Wojtowycz 1999; Tokunaga et al. 2000) and, as far as
suggested as proxies for quality of care (Howie et al. consultation time is concerned, with quality of care (Howie
2000) and could be used for comparison of hospital et al. 1989,1991,1997,1998,1999,2000).
outpatient vs. primary care facilities, or, of public vs. In terms of patient-centredness the publicprivate dif-
private providers. They are, however, no substitute for ferences have to be qualified. Consultations by private
direct observation. Direct observation of consultation is practitioners were significantly more patient-centred than
obviously subject to bias. One way to limit bias in the those in public facilities. This was mainly the case in
observation of consultations is to use simulated patients. private clinics where the scores were twice as high as in the
Simulated patients have been used before, for studies of public sector. The difference in patient-centred care was
drug shops, pharmacies, family planning services or to much less pronounced in private hospitals. The greater
look at how doctors and nurses prescribe drugs (Madden degree of patient-centredness in the private sector is most
et al. 1997). The use of simulated patients in this study likely the result of the economic incentives to provide
made it possible to provide first-hand direct information patient friendliness, which is what one would expect for
on various aspects of outpatient care with minimal private providers who work on a fee-for-service basis. At
observation bias. Standardized case histories and cue least in part it is also closely related to the greater length of
questions, in combination with blinded analysis of the the consultations and particularly of the fact that patients
consultation tapes and transcripts, allowed for a stan- receive a greater opportunity to express themselves. With

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Y. Pongsupap & W. Van Lerberghe Choosing between public and private or between hospital and primary care

half a minute for this, as in public facilities, a patient- mentary investigations in one-third of consultations. This
centred approach must be nearly impossible. There is not was considerably more than in both public health centres
much more time in consultations with private practition- and private clinics, suggesting that the bio-technological bias
ers, but even small differences in time for patients to of the professional environment is an important reason for
express themselves apparently make a difference. A over-prescription by itself, and only enhanced by the
patient-centred approach is obviously related to respon- perverse financial incentives in private hospitals. In health
siveness, but there is more to it than just that. It goes to the centres and clinics, where the technology was not directly
core of an effective consultation (Henbest & Fehrsen available and when there was little to be gained from
1992), especially for the kind of complaints presented by recommending such investigations, patients were less likely
the simulated patients in this study (Roter et al. 1997). In to get complementary investigations. The possibility of being
this sense, the degree of patient-centred approach is prescribed such examinations was lowest in public health
directly relevant to quality of care in these consultations. centres run by GPs. In both public and private settings the
Although there are publicprivate differences in patient- total cost of prescribed drugs and recommended investiga-
centred care, very few doctors, be they public or private, got tions was slightly higher for doctors whose patient-centred-
high scores. All services left a lot to be desired in terms of ness scores were in the bottom quartile (respectively 13.7 and
patient-centred care. Few showed propensity or capacity for 29.6 US$) than for those in the top quartile (respectively 12.3
listening. Patients were most often not helped to express their and 29.6 US$).
concerns or not even given the opportunity to do so, In many developing countries, particularly in urban
although they did have more time to offer hints in the longer areas, health care is reduced to its bio-technological
private consultations. Answers were usually closed and dimension. Doctors in Bangkok are no exception, be they
stereotyped. The complaints apparently triggered a categ- private practitioners or working in the public sector. Apart
orization by the doctors (private and public alike) in terms of from the resulting lack of patient-centred care, ineffec-
gastritis stress-eating behaviour. Doctors started explain- tiveness and iatrogenesis this has major consequences for
ing this nosological interpretation to the patient very early in the cost of health care to the patients.
the consultation, at the expense of listening. Since in Thai The direct cost to the patient is higher in hospitals than
culture patients have to pay respectful attention to what the in a primary care setting, higher for a specialist consulta-
doctor says, cue questions could often only be asked at the tion than with a GP, and higher in the private than in the
end of consultation. By that time the opportunity for public sector. Private hospitals are significantly more
interaction was lost as doctors were seeking to end the expensive than all the other facilities. However, if one
consultation. This pattern was the same in both public and takes into account the government subsidies to the public
private settings. It is consistent with the observation that the facilities, private clinics surprisingly come out as having the
time allowed for patients to speak was related to the patient- lowest service costs. Much of this due to the investigations
centred care score, whereas the time the doctor spent talking prescribed during consultation in public facilities.
to their patients was not. Thai patients are correct in their expectations of private
Doctors showed little more propensity or capacity for facilities, which show a great degree of responsiveness and
counselling. Many seem to have recognized anxiety and of patient-centred care, though at a price in terms of money
fear as a key feature of their patients history. They did not, and potential ill effects from unnecessary prescriptions.
however, respond with information, reassurance or coun- The comparative advantage of private facilities, however,
selling. Rather, they relied on tranquilizers or recommen- must be qualified. If patients wish to receive a service
dations for endoscopy or barium meal investigation. which includes the highest levels of responsiveness and
One would expect doctors in the public sector to be more patient-centred care, and minimize costs and iatrogenesis,
concerned with rational and parsimonious prescribing than it would be advisable to avoid hospitals, public or private,
private doctors. This was indeed the case, and the drug bills and to a lesser extent specialists. By choosing a primary
of private doctors were at least double of those in public care provider i.e., a health centre or clinic, where they are
facilities. Nevertheless, all doctors, including those in public attended by a GP, they are more likely to receive a service
facilities, wrote potentially iatrogenic prescriptions of a fulfiling their expectations, rather than choosing between a
multitude of inappropriate drugs. Doctors in private hospi- public or private provider. Primary care facilities prescribe
tals were not only the ones to prescribe most drugs, they also fewer unnecessary drugs and technical examinations. They
asked for most follow-up investigations: the technology is do so at the lowest direct cost for the patient, and, in the
available and there is a financial incentive to make use of it. case of the private clinics, in the most responsive and
In public hospitals, however, the financial incentives are less patient-centred manner, among the different providers of
relevant, but doctors also recommended expensive comple- ambulatory care in Bangkok.

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Y. Pongsupap & W. Van Lerberghe Choosing between public and private or between hospital and primary care

The first and most important choice patients have to Howie JG, Heaney DJ & Maxwell M (1997) Measuring quality in
make in Bangkok is what level of health care they will use. general practice. Pilot study of a needs, process and outcome
The choice between private or public provider comes second. measure. Occasional Papers of Royal College General Practice
The behaviour of physicians in public and private hospitals 75, ixii, 132.
Howie JG, Heaney DJ, Maxwell M & Walker JJ (1998) A com-
suggests that incentives for primary care gate keeping (such
parison of a Patient Enablement Instrument (PEI) against two
as better pay, better training and more realistic workload)
established satisfaction scales as an outcome measure of primary
and a more appropriate medical culture are priorities to care consultations. Familial Practice 15, 165171.
improve the quality of care patients receive. The information Howie JG, Heaney DJ, Maxwell M, Walker JJ & Freeman GK
gained from the direct observation of doctors in their day-to- (2000) Developing a consultation quality index (CQI) for use
day practice shows the importance of organizing some form in general practice. Familial Practice 17, 455461.
of consumer protection in medical systems where provider Howie JG, Heaney DJ, Maxwell M, Walker JJ, Freeman GK &
behaviour is largely unregulated. Rai H (1999) Quality at general practice consultations: cross
sectional survey. BMJ 319, 738743.
Howie JG, Porter AM & Forbes JF (1989) Quality and the use of
Acknowledgements time in general practice: widening the discussion. BMJ 298,
10081010.
We are grateful to Dr. Banpot Pinitchan for his assistance
Howie JG, Porter AM, Heaney DJ & Hopton JL (1991) Long
with the quality control of the scoring and to Ms. Supattra to short consultation ratio: a proxy measure of quality of care
Toviriyavej and Ms Jiraporn Chanpeng for their help in for general practice. British Journal of General Practice 41,
organising the field operations, and Dr Megan Crofts for 4854.
reviewing the manuscript. This research was made possible Laslett AM, Brown S & Lumley J (1997) Womens views of different
by a grant from the EC funded Health Care Reform project models of antenatal care in Victoria, Australia. Birth 24, 8189.
(ALA/94/28), contract nr 107. Lertiendumrong J (2001) Unit Cost of Care at General and
Regional Hospitals in 19992000, Health System Research
Institute, Bangkok.
References Madden JM, Quick JD, Ross-Degnan D & Kafle KK (1997)
Undercover careseekers: simulated clients in the study of health
Ahmed AM, Urassa DP, Gherardi E & Game NY (1996) Patients
provider behavior in developing countries. Social Science
perception of public, voluntary and private dispensaries in rural
Medical 45, 14651482.
areas of Tanzania. East African Medical Journal 73, 370374.
Mulou N, Thomason J & Edwards K (1992) The rise of private
Andaleeb SS (2000) Service quality in public and private hospitals in
practice: a growing disquiet with public services? PNG Medical
urban Bangladesh: a comparative study. Health Policy 53, 2537.
Journal 35, 171178.
Brown S & Lumley J (1993) Antenatal care: a case of the inverse
Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles W & Inui
care law? Australian Journal of Public Health 17, 95103.
TS (1997) Communication patterns of primary care physicians.
Camilleri D & OCallaghan M (1998) Comparing public and
JAMA 277, 350356.
private hospital care service quality. International Journal of
Tangcharoensathien V, Bennett S, Khongswatt S, Supacutikul A &
Health Care Quality Assurance Inc. Leadership Health Service
Mills A (1999) Patient satisfaction in Bangkok: the impact of
11, 127133.
hospital ownership and patient payment status. International
Dye TD & Wojtowycz MA (1999) Organisational variation,
Journal of Quality Health Care 11, 309317.
satisfaction, and womens time investment in prenatal care.
Tengilimoglu D, Kisa A & Dziegielewski SF (1999) Patient
Paediatrics Perinatal Epidemiology 13, 158169.
satisfaction in Turkey: differences between public and private
Ellis RP, McInnes DK & Stephenson EH (1994) Inpatient and
hospitals. Journal of Community Health 24, 7391.
outpatient health care demand in Cairo, Egypt. Health Eco-
Tokunaga J, Imanaka Y & Nobutomo K (2000) Effects of patient
nomics 3, 183200.
demands on satisfaction with Japanese hospital care. Interna-
Ferrinho P, Bulgalho A & Van Lerberghe W (2001) Is there a case
tional Journal of Quality Health Care 12, 395401.
for privatising reproductive health? Patchy evidence and much
Yedidia MJ (1994) Differences in treatment of ischemic heart
wishful thinking. Studied in Health Services Organisation and
disease at a public and a voluntary hospital: sources and con-
Policy 18, 343370.
sequences. Milbank Quarterly, 72, 299327.
Henbest RJ & Fehrsen GS (1992) Patient-centredness: is it
applicable outside the West? Its measurement and effect on
outcomes. Familial Practice 9, 311317.

Corresponding Author
Yongyuth Pongsupap, National Health Security Office, Nonthaburi, Thailand. E-mail yongyuth.p@nhso.go.th.

88 2005 Blackwell Publishing Ltd


Tropical Medicine and International Health volume 11 no 1 pp 8189 january 2006

Y. Pongsupap & W. Van Lerberghe Choosing between public and private or between hospital and primary care

Choisir entre secteur public et prive ou entre hopital et soin primaire: Reponse, approche centree sur le patient et profils des prescriptions dans les
consultations de patients ambulants a` Bangkok

objectif Documenter les differences de comportement chez les praticiens entre secteur prive et public, dans les services de patients ambulants des
hopitaux, des centres de sante et des cliniques de Bangkok, Thalande.
Methode Analyse des caracteristiques de 211 consultations enregistrees avec des patients simules.
resultats Les hopitaux et cliniques prives repondaient de facon plus significative. Les cliniques privees mais pas les hopitaux prives, avaient une
approche plus centree sur le patient. Tous les medecins et en particulier ceux des hopitaux prives, prescrivaient des examinations techniques et des
medicaments non necessaires et potentiellement dangereux. Le cout directe pour le patient variait entre 1.5 (dans les centres de sante publique) et 12
(dans les hopitaux prives) fois le revenu minimal journalier. Le cout combine, pour le patient et letat, dans les hopitaux publics et les centres de sante
de`passait le cout des consultations dans les cliniques privees.
conclusion Les incitations du marche favorisent la reponse et lapproche centree sur le patient, mais pas plus de decisions therapeutiques appropriees.
Lutilisation excessive de medicaments est observee autant chez les praticiens du secteur public que du secteur prive. Mais, elle est plus accentuee dans les
hopitaux prives. Si les patients a` Bangkok veulent maximiser la reponse et le degre dapproche centree sur le patient en minimisant les couts et les effets
iatroge`nes, ils beneficieraient en evitant autant les hopitaux publics que prives et, dans une moindre mesure les specialistes. Choisir lutilisation des
secteurs de soin primaire, des centres de sante et des cliniques - en particulier lorsque les consultations sont menees par un medecin generaliste - est plus
benefique que choisir entre dispensateurs publics et prives.

Mots cles reponse, approche centree sur le patient, medication, soin de patients ambulants, cout, patients simules, prescription, publicprive, protection
des consommateurs

Eleccion entre atencion publica o privada y entre atencion primaria u hospitalaria: interes, dedicacion al paciente y patrones de prescripcion en
consultas externas en Bangkok

objetivo Documentar las diferencias en comportamiento del proveedor entre hospitales privados y publicos en consultas externas, centros de salud y
clnicas en Bangkok, Tailandia.
metodo Analisis de las caractersticas de 211 consultas grabadas con pacientes simulados.
resultados Los hospitales privados y las clnicas tuvieron una respuesta significativamente mejor. Las clnicas privadas, mas no los hospitales
privados, tambien tenan una mayor dedicacion al paciente. Todos los medicos, pero particularmente aquellos de hospitales privados, prescribieron
medicamentos innecesarios as como tecnicas o medicamentos bajo investigacion potencialmente peligrosos. El coste directo al paciente variaba entre
1.5 (en centros de salud publicos) y 12 (en hospitales privados) veces la salario diario mnimo. El costo combinado al paciente y al estado en
hospitales publicos y centros de salud excedio el costo de las consultas en clnicas privadas.
conclusion Los incentivos del mercado favorecen el interes y la dedicacion al paciente, pero no la toma de decisiones terapeuticas apropiadas. Se
observo un uso excesivo de farmacos tanto el los hospitales publicos como privados, pero de forma mas pronunciada en los hospitales privados. Si los
pacientes de Bangkok desean maximizar el interes y el grado de dedicacion en la atencion y ademas minimizar los costos y la iatrogenia, deberan evitar
los hospitales, tanto publicos como privados, y en menor extension a los especialistas. Escoger el usar servicios primarios, centros de salud y clnicas,
particularmente cuando las consultas son realizadas por medicos generales, es mas benefico que escoger entre proveedores publicos y privados.

Palabras clave interes, dedicacion en el cuidado del paciente, medicacion, consultas externas, pacientes simulados, prescripcion, publico-privado,
proteccion al consumidor

2005 Blackwell Publishing Ltd 89

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