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Background Multimorbidity in primary care is a challenge not only for developing countries but also for low and medium income countries (LMIC). Health services in LMIC countries are being provided by both public and private health care providers. However, a critical knowledge gap exists on understanding the true extent of multimorbidity in both types of primary care settings. Methods We undertook a study to identify multimorbidity prevalence and healthcare utilization among both public and private primary care attendees in Odisha state of India. A total of 1649 patients attending 40 primary care facilities were interviewed using a structured multimorbidity assessment questionnaire collecting information on 22 chronic diseases, medication use, number of hospitalization and number of outpatient visits. Result The overall prevalence of multimorbidity was 28.3% and nearly one third of patients of public facilities and one fourth from private facilities had multimorbidity. Leading diseases among patients visiting public facilities included acid peptic diseases, arthritis and chronic back pain. No significant difference in reporting of hypertension and diabetes across the facilities was seen. Besides age, predictors of multimorbidity among patients attending public facilities were, females [AOR: 1.6; 95% CI 1.1–1.3] and non-aboriginal groups [AOR: 1.6; 95%CI 1.1–2.3] whereas, in private females [AOR: 1.6; 95%CI 1.1–2.4], better socioeconomic conditions [AOR 1.4; 95% CI 1.0–2.1] and higher educational status [primary school completed [AOR 2.6; 95%CI 1.6–4.2] and secondary schooling and above [AOR 2.0; 95%CI 1.1–3.6] with reference to no education were seen to be the determinants of multimorbidity. Increased number of hospital visits to public facilities were higher among lower educational status patients [IRR: 1.57; 95% CI 1.13–2.18] whereas, among private patients, the mean number of hospital visits was 1.70 times more in higher educational status [IRR: 1.70; 95%CI 1.01–3.69]. The mean number of medicines taken per day was higher among patients attending private hospitals. Conclusion Our findings suggest that, multimorbidity is being more reported in public primary care facilities. The pattern and health care utilization in both types of settings are different. A comprehensive care approach must be designed for private care providers.

Objective To evaluate patients’ satisfaction and loyalty to private hospitals and to identify factors influencing patient loyalty. Design A cross-sectional, population-based study was conducted between May and September of 2005. Setting Sana'a, the capital city of the Republic of Yemen. Participants Eight hundred and nineteen respondents who were admitted for at least 1 day in a private hospital within last 6 months from the date of interview. Main Outcome Measures The scores on the modified SERVQUAL market research instrument including six domains (tangibility, reliability, responsiveness, assurance, empathy and cost) that identify perceptions of service quality. In addition, the respondents were asked whether or not they would return to the same facility when they need future medical care (loyalty). Results Loyalty was higher among females [odds ratio (OR) = 1.44; P < 0.05], among those reporting higher reliability scores (OR = 1.24; P < 0.01), higher assurance scores (OR = 1.2; P < 0.01) and higher empathy scores (OR = 1.13; P < 0.05) and also among those reporting higher cost (OR = 1.15; P<0.05). No significant association was found between patient loyalty and, tangibility and responsiveness score. Conclusions Improvements are required to achieve high-quality healthcare services in the private hospitals in Yemen and increase loyalty among patients. Findings from this study could inform private sector healthcare development in low- and middle-income countries.

Background People with Parkinson's disease (PD) do not always access specialist outpatient services in a timely manner in Ireland. The perspectives of people living with PD, relating to service access, are largely absent in the existing literature. Aim To explore experiences of PD service access for people living with PD, using a qualitative approach. Methods Purposive maximum variation sampling was used. Semi‐structured telephone interviews were conducted with 25 service users, including people with PD (n = 22) and supporting carers (n = 3). Informed consent was obtained from all participants. Interviews ranged in duration from 30 to 90 min. Data were managed in NVivo 12 and interpreted inductively using thematic analysis. The researchers were reflexive throughout the research process. The Consolidated Criteria for Reporting Qualitative Research checklist was employed to maximise transparency. Results The findings highlight several key barriers to and facilitators of equitable and timely service access. Three key themes were identified comprising experiences of PD service access including ‘geographical inequity’, ‘discriminatory practices’, and ‘public and private system deficits’. Together, these themes illustrate how a two‐tiered and under‐resourced health system lacks capacity, in terms of infrastructure and workforce, to meet PD needs for both public and private patients in Ireland. Conclusions These findings point to problems for PD care, relating to (i) how the health system is structured, (ii) the under‐provision and under‐resourcing of specialist outpatient PD services, including medical, nursing, and multidisciplinary posts, and (iii) insufficient PD awareness education and training across health settings. The findings also show that telemedicine can provide opportunities for making access to certain aspects of PD care more flexible and equitable, but the feasibility and acceptability of technology‐enabled care must be assessed on an individual basis. Implications for policy, practice and research are discussed. Patient or Public Contribution The design and conduct of this study were supported by an expert advisory group (EAG) of 10 co‐researchers living with PD. The EAG reviewed the interview schedule and the protocol for this study and provided detailed feedback from their perspective, to improve the methods, including the interview approach. The group also reviewed the findings of the study and contributed their insights on the meaning of the findings, which fed into this paper.

This study aimed to explore the contextual and multilevel challenges to promoting exercise engagement among prostate cancer survivors in a low-resource setting, with a focus on integrating exercise-based rehabilitation into routine care and survivorship care planning, using a qualitative approach grounded in interpretative description. Sixteen prostate cancer survivors (aged 53-77 years) were purposively sampled from public and private healthcare facilities in Cape Town, South Africa. Semi-structured telephonic interviews were conducted using a topic guide informed by prior research. Interviews were audio-recorded, transcribed verbatim, and analysed thematically. Four major themes were identified. Findings highlighted stark contrasts in exercise engagement between men treated in private versus public healthcare settings. Exercise was essential to private patients, whereas most public patients showed limited interest. Factors influencing engagement included knowledge gaps, treatment complications, fear of worsening symptoms, and age-related comorbidities. Socio-environmental barriers-such as neighbourhood safety and poor work-life balance-reduced exercise opportunities. Facility-level issues included inconsistent messaging from providers, lack of exercise oncology pathways, and absent referral systems. Our study identified key multilevel influences surrounding exercise promotion and integration in routine care for prostate cancer survivors receiving treatment in private and public healthcare settings. While highlighting the opportunities/challenges surrounding integrating exercise programs in routine management, our findings offer program planners valuable insights for planning and developing interventions in resource-constrained settings.

The establishment of internal markets for healthcare provision in publicly-funded healthcare systems brings forth a number of new regulatory challenges. During the 2003 healthcare reform in Turkey, universal health coverage (UHC) was implemented concurrently with the establishment of an internal market for service provision, resulting in an increase in private sector activity. In this context, this paper explores how, in the Turkish case, the macro-level adoption of an internal market model for healthcare provision has shaped patient experiences at the micro-level in their ability to receive treatment in private hospitals offering publicly-funded services (PHOPS). It also examines the influence of the internal market on the realised publicness of healthcare services in Turkey. Data for the study were obtained from patient complaints that appeared on a private online platform and 20 patient interviews. These showed that patients sometimes face significant challenges, including pressure to make informal payments, when accessing their entitlements, which is evidence of the erosion of publicness in a hybrid healthcare system. These challenges emerge from information asymmetry between patients and providers; a large space for PHOPS to manoeuvre when deciding to register patients as insurance holders or private patients; and the ineffective public regulation of the internal market.

Abstract Objective: To assess and compare the preferences of pregnant women in the public and private sector regarding delivery in Brazil. Design: Face to face structured interviews with women who were interviewed early in pregnancy, about one month before the due date, and about one month post partum. Setting: Four cities in Brazil. Participants: 1612 pregnant women: 1093 public patients and 519 private patients. Main outcome measures: Rates of delivery by caesarean section in public and private institutions; women's preferences for delivery; timing of decision to perform caesarean section. Results: 1136 women completed all three interviews; 476 women were lost to follow up (376 public patients and 100 private patients). Despite large differences in the rates of caesarean section in the two sectors (222/717 (31%) among public patients and 302/419 (72%) among private patients) there were no significant differences in preferences between the two groups. In both antenatal interviews, 70-80% in both sectors said they would prefer to deliver vaginally. In a large proportion of cases (237/502) caesarean delivery was decided on before admission: 48/207 (23%) in women in the public sector and 189/295 (64%) in women in the private sector. Conclusions: The large difference in the rates of caesarean sections in women in the public and private sectors is due to more unwanted caesarean sections among private patients rather than to a difference in preferences for delivery. High or rising rates of caesarean sections do not necessarily reflect demand for surgical delivery. What is already known on this topic In Brazil, one quarter of all women deliver in the private sector The rate of caesarean deliveries in the private sector is extremely high (70%) and more than twice that in the public sector, where rates have recently fallen due to a new policy Previous studies in which women were interviewed after birth showed that a substantial proportion of private patients who have caesarean sections would have preferred normal delivery What this study adds In two antenatal interviews, preferences regarding type of delivery were nearly identical among public and private patients and strongly favoured vaginal births Contrary to popular belief, middle and upper class women in Brazil do not want to deliver by caesarean section

Ageing populations and age-related morbidity present major challenges for advanced economies in managing rapidly increasing pharmaceutical expenditures. However, older people, particularly those with low incomes, may be susceptible to negative effects from cost sharing for medicines. The impact of introducing prescription drug co-payments for older publicly insured patients (medical cardholders) in Ireland is explored using data from The Irish Longitudinal Study on Ageing. Difference-in-difference analysis revealed that medicines use increased despite the imposition of small co-payments for medical cardholders (the treatment group) relative to a control group of private patients. However, features of the Irish market must be taken into account in interpreting this counterintuitive result.

The private for-profit sector is an important source of treatment for malaria. However, private patients face high prices for the recommended treatment for uncomplicated malaria, artemisinin combination therapies (ACTs), which makes them more likely to receive cheaper, less effective non-artemisinin therapies (nATs). This study seeks to better understand consumer antimalarial prices by documenting and exploring the pricing behaviour of retailers and wholesalers. Using data collected in 2009-10, we present survey estimates of antimalarial retail prices, and wholesale- and retail-level price mark-ups from six countries (Benin, Cambodia, the Democratic Republic of Congo, Nigeria, Uganda and Zambia), along with qualitative findings on factors affecting pricing decisions. Retail prices were lowest for nATs, followed by ACTs and artemisinin monotherapies (AMTs). Retailers applied the highest percentage mark-ups on nATs (range: 40% in Nigeria to 100% in Cambodia and Zambia), whereas mark-ups on ACTs (range: 22% in Nigeria to 71% in Zambia) and AMTs (range: 22% in Nigeria to 50% in Uganda) were similar in magnitude, but lower than those applied to nATs. Wholesale mark-ups were generally lower than those at retail level, and were similar across antimalarial categories in most countries. When setting prices wholesalers and retailers commonly considered supplier prices, prevailing market prices, product availability, product characteristics and the costs related to transporting goods, staff salaries and maintaining a property. Price discounts were regularly used to encourage sales and were sometimes used by wholesalers to reward long-term customers. Pricing constraints existed only in Benin where wholesaler and retailer mark-ups are regulated; however, unlicensed drug vendors based in open-air markets did not adhere to the pricing regime. These findings indicate that mark-ups on antimalarials are reasonable. Therefore, improving ACT affordability would be most readily achieved by interventions that reduce commodity prices for retailers, such as ACT subsidies, pooled purchasing mechanisms and cost-effective strategies to increase the distribution coverage area of wholesalers.