Concentration and fragmentation: analysing the implications of the structure of Georgia's private healthcare market for quality and accessibility

集中化和分散化：分析佐治亚州私人医疗保健市场结构对质量和可及性的影响

• 批准号: MR/T018062/1
• 负责人: George Gotsadze
• 金额: $ 23.1万
• 依托单位: Curatio International Foundation
• 依托单位国家: 英国
• 项目类别: Research Grant
• 财政年份: 2020
• 资助国家: 英国
• 起止时间: 2020 至 无数据
• 项目状态: 已结题
• 来源: https://gtr.ukri.org/projects?ref=MR%2FT018062%2F1
• 关键词: Concentration; fragmentation; analysing; implications; structure

The private sector is increasingly recognized as playing an important role in health systems in low- and middle-income countries (LMIC), yet policymakers struggle to identify the role of the private sector in relation to their Universal Health Coverage objectives. Developing policies for engaging with private health care providers requires a good understanding of how healthcare markets operate. Markets are described according to their market structure which can range from highly fragmented (a large number of small firms), through to highly concentrated (one or a few large firms, including those where providers have invested in diagnostic facilities or pharmaceuticals). While the risks of excess concentration have long been recognised, evidence is emerging from a number of LMICs about the potential risks to patients of excess fragmentation. These include quality of care, if treatment volumes are too small to be safe or where opportunities for training are absent; or health system risks, arising from the difficulties of purchasing from or regulating large numbers of small providers.The overall aim of this study is to elaborate this conceptual framing of risks of harm from concentration and fragmentation of healthcare markets and develop a set of tools for undertaking healthcare market analysis that can inform policy options for shaping healthcare markets in the context of UHC. We will undertake this research in Georgia, a lower-middle income former soviet country which has undergone extensive privatisation. This award will set the foundation for evaluating future policy changes in Georgia and extendingt the analytic approach to other settings in a future research project. We will achieve this aim through 4 specific research questions: 1. What is the structure and nature of the healthcare market in Georgia: to what extent is the market characterized by fragmentation and concentration, and by horizontal and vertical integration?2. What demand, supply and policy factors are driving this pattern? 3. What are the risks and benefits for patients, and for the health system, of fragmented and consolidated health service provision? 4. What policy levers are available to shape the private healthcare market to better serve the needs of UHC? The study uses a mixed methods approach, collecting qualitative interview data and undertaking quantitative analysis of large social insurance databases. We will describe the Georgian healthcare market in terms of types of business and market structure, explore the reasons for the patterns that we observe, and then construct "theories of harm" which will describe the potential risks to patients and to the health system of fragmentation and concentration. We will use quantitative methods applied to insurance claims data to look at the extent to which key individual outcomes such as price and intensity of treatment, and system level outcomes such as accessibility, approaches to quality assurance and the costs of contracting and regulating, differ by provider business model and market structure. Findings will be presented at a series of structured policy dialogues, to validate our data and interpretations, and to develop potential policy interventions. These will engage a wide variety of health policy stakeholders and consider how to shape private health care markets through for example, changes in regulation and purchasing policies, so that they operate in the interests of UHC.This project is being proposed by a highly experienced, multidisciplinary, international research team with strong connections at the national, regional and global level to support the achievement of research impact. Capacity will be developed in both directions, with Georgian colleagues gaining exposure to approaches to researching the private sector as well as analysis of large administrative datasets, and UK collaborators learning about the nature of privatization in a former Soviet setting.

人们越来越认识到私营部门在低收入和中等收入国家 (LMIC) 卫生系统中发挥着重要作用，但政策制定者很难确定私营部门在实现全民健康覆盖目标方面的作用。制定与私营医疗保健提供者合作的政策需要充分了解医疗保健市场的运作方式。市场根据其市场结构进行描述，其范围可以从高度分散（大量小公司）到高度集中（一家或几家大公司，包括供应商投资诊断设施或药品的公司）。虽然人们早已认识到过度集中的风险，但许多中低收入国家正在出现证据表明过度碎片化对患者存在潜在风险。这些包括护理质量，如果治疗量太小而不安全或缺乏培训机会；或因向大量小型供应商采购或监管困难而产生的卫生系统风险。本研究的总体目标是详细阐述医疗保健市场集中和分散造成的危害风险的概念框架，并开发一套用于进行医疗保健市场分析的工具，为在全民健康覆盖背景下塑造医疗保健市场的政策选择提供信息。我们将在格鲁吉亚进行这项研究，格鲁吉亚是一个中低收入的前苏联国家，已经经历了广泛的私有化。该奖项将为评估乔治亚州未来的政策变化奠定基础，并将分析方法扩展到未来研究项目的其他环境。我们将通过四个具体的研究问题来实现这一目标： 1. 格鲁吉亚医疗保健市场的结构和性质是什么：市场在多大程度上呈现分散化和集中化、横向和纵向一体化的特征？ 2．哪些需求、供给和政策因素正在推动这种模式？ 3. 分散和整合的卫生服务提供对患者和卫生系统有哪些风险和好处？ 4. 有哪些政策杠杆可以塑造私营医疗保健市场，以更好地满足全民健康覆盖的需求？该研究采用混合方法，收集定性访谈数据并对大型社会保险数据库进行定量分析。我们将从业务类型和市场结构方面描述格鲁吉亚医疗保健市场，探讨我们观察到的模式的原因，然后构建“危害理论”，该理论将描述患者以及分散和集中的卫生系统的潜在风险。我们将使用应用于保险索赔数据的定量方法来研究关键的个人结果（例如价格和治疗强度）以及系统级结果（例如可及性、质量保证方法以及签约和监管成本）在多大程度上因提供商的商业模式和市场结构而异。研究结果将在一系列结构化政策对话中提出，以验证我们的数据和解释，并制定潜在的政策干预措施。这些将吸引广泛的卫生政策利益相关者，并考虑如何通过监管和购买政策的变化等来塑造私人医疗保健市场，以便它们的运作符合全民健康覆盖的利益。该项目由经验丰富的多学科国际研究团队提出，在国家、区域和全球层面拥有密切的联系，以支持实现研究影响。能力将在两个方向上发展，格鲁吉亚同事将接触到研究私营部门的方法以及大型行政数据集的分析，而英国合作者将了解前苏联环境下私有化的本质。

项目成果

Coverage without financial protection - why does catastrophic health expenditure persist under some UHC schemes and what can we do about it?!

没有经济保障的承保 - 为什么在一些全民健康覆盖计划下灾难性的医疗支出持续存在，我们能做些什么？！

• 发表时间: 2022
• 作者: Gotsadze G

Risks from healthcare market fragmentation: learning lessons from Georgia

医疗保健市场碎片化的风险：从格鲁吉亚吸取教训

• 发表时间: 2022
• 作者: Tvaliashvili M.

Too concentrated and too fragmented? An analysis of outpatient and inpatient market structure in Georgia

太集中又太分散？

• 发表时间: 2021
• 作者: Goodman C

Special issue of Healthcare Barometer- Health service market in Georgia: associated harms and benefits

医疗晴雨表特刊 - 格鲁吉亚的医疗服务市场：相关危害和好处

• 发表时间: 2021
• 作者: Gotsadze G

Concentration and Fragmentation in the Market for Healthcare Services in Georgia

格鲁吉亚医疗服务市场的集中和分散

• 发表时间: 2021
• 作者: Tvaliashvili M