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

私营部门在低收入和中等收入国家的保健系统中发挥着重要作用，这一点日益得到承认，但政策制定者难以确定私营部门在实现全民保健目标方面的作用。制定与私营医疗保健提供者接触的政策需要对医疗保健市场如何运作有很好的了解。市场根据其市场结构进行描述，从高度分散(大量小公司)到高度集中(一家或几家大公司，包括那些供应商投资于诊断设施或药品的公司)。虽然过度集中的风险早已被认识到，但一些LMIC正在出现关于过度碎裂对患者的潜在风险的证据。这包括医疗质量，如果治疗量太小而不安全或没有培训机会；或者卫生系统风险，由从大量小供应商购买或监管的困难产生。这项研究的总体目标是阐述医疗市场集中和分散的损害风险的概念框架，并开发一套进行医疗市场分析的工具，为在UHC背景下塑造医疗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。这一奖项将为评估佐治亚州未来的政策变化奠定基础，并在未来的研究项目中将分析方法扩展到其他环境。我们将通过四个具体的研究问题来实现这一目标：1.佐治亚州医疗市场的结构和性质：市场在多大程度上以分散和集中以及横向和垂直一体化为特征？2.什么需求、供给和政策因素在推动这种模式？3.分散和整合的医疗服务提供对患者和医疗系统有什么风险和好处？4.有哪些政策杠杆可以塑造私营医疗市场，以更好地服务于UHC的需求？本研究采用混合方法，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的角度描述格鲁吉亚的医疗市场，探索我们观察到的模式的原因，然后构建描述分散和集中的患者和医疗系统的潜在风险的“危害理论”。我们将使用应用于保险索赔数据的量化方法，以查看关键的个人结果(如价格和治疗强度)和系统级别结果(如可获得性、质量保证方法以及合同和监管成本)在多大程度上因提供商的商业模式和市场结构而异。调查结果将在一系列有组织的政策对话中公布，以验证我们的数据和解释，并制定潜在的政策干预措施。该项目由一支经验丰富、多学科的国际研究团队提出，他们在国家、地区和全球层面有着强大的联系，以支持研究影响力的实现。将向两个方向发展能力，格鲁吉亚的同事将接触到研究私营部门的方法以及对大型行政数据集的分析，而英国的合作者将了解前苏联背景下私有化的性质。

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.