Hybrid Organizations in Health Systems: The Corporatization of Malaysia's National Heart Institute.

Health system reforms across high- and middle-income countries often involve changes to public hospital governance. Corporatization is one such reform, in which public sector hospitals are granted greater functional independence while remaining publicly owned. In theory, this can improve public hospital efficiency, while retaining a public service ethos. However, the extent to which efficiency gains are realized and public purpose is maintained depends on policy choices about governance and payment systems. We present a case study of Malaysia's National Heart Institute (IJN), which was created in 1992 by corporatization of one department in a large public hospital. The aim of the paper is to examine whether IJN has achieved the goals for which it was created, and if so, whether it provides a potential model for further reforms in Malaysia and other similar health systems. Using a combination of document analysis and key informant interviews, we examine key governance, health financing and payment, and equity issues. For governance, we highlight the choice to have IJN owned by and answerable to a Ministry of Finance (MOF) holding company and MOF-appointed board, rather than the Ministry of Health (MOH). On financing and payment, we analyze the implications of IJN's combined role as fee-for-service provider to MOH as well as provider of care to private patients. For equity, we analyze the targeting of IJN care across publicly-referred and private patients. These issues demonstrate unresolved tensions between IJN's objectives and public service goals. As an institutional innovation that has endured for 28 years and grown dramatically in size and revenue, IJN's trajectory offers critical insights on the relevance of the hybrid public-private models for hospitals in Malaysia as well as in other middle-income countries. While IJN appears to have achieved its goal of establishing itself as a commercially viable, publicly owned center of clinical excellence in Malaysia, the value for money and equity of the services it provides to the Ministry of Health remain unclear. IJN is accountable to a small Ministry of Finance holding company, which means that detailed information required to evaluate these critical questions is not published. The case of IJN highlights that corporatization cannot achieve its stated goals of efficiency, innovation, and equity in isolation; rather it must be supported by broader reforms, including of health financing, payment, governance, and transparency, in order to ensure that autonomous hospitals improve quality and provide efficient care in an equitable way.

The Perils of Privatization: Bringing the Business Model into Human Services.

During the last three decades in both the United States and Europe, neoliberal policies, especially privatization, have restructured services in ways that dramatically affect the capacity of human services workers and agencies to serve all clients. Privatization means not only transforming public programs such as Social Security, but also managerialism-the incorporation of business principles, methods, and goals into public and nonprofit human services organizations. Few researchers have looked at the impact of market-based managerialism (focused on productivity, accountability, efficiency, and standardization) on social work's mission and the effectiveness of human services workers and organizations. Using an anonymous survey of 3,000 New York City human services workers, authors examined the impact of managerialist practices including performance measures, quantifiable short-term outcomes, and routinized practices on frontline workers and service provision. A troubling trend emerged. Workers in agencies with a high commitment to managerialism found it considerably more difficult to adhere to social work's mission and fundamental values. This conflict between the "logic of the market" and the "logic of social work" subsided dramatically in agencies with a low commitment to managerialism, indicating that even in today's competitive environment, agencies can protect the social work mission.

Price Changes in Washington Following the 2012 Liquor Privatization: An Update Through 2016 With Comparisons to California, Idaho, and Oregon.

BACKGROUND: Washington State ended their wholesale and retail monopoly on liquor on June 1, 2012, resulting in a 5-fold increase in liquor outlets in diverse store types. The legislation also included taxes at the wholesale and retail levels. This study seeks to investigate whether prices have changed from 2014 through 2016, as a follow-up to a previous study finding increases in prices from 2012 to 2014, compared to prices in other states. METHODS: We developed an index of 68 brands that were popular in Washington in early 2012. Data on final liquor prices (including taxes) in Washington and California were obtained through store visits and online sources between November 2013 and March 2014, and again between April and May 2016 for Washington only. Pricing data for Idaho and Oregon were obtained from the Statistics for Alcohol Management Database over both sampling periods. Primary analyses were conducted on the utmost brands available in the majority of the stores sampled. RESULTS: Liquor prices in Washington rose an average of 3.9% for 750 ml and 6.5% for 1.75-l containers overall from 2014 to 2016, while bordering states Idaho (+2.9%) and Oregon (+1.5%) experienced smaller increases for 750-ml and declines for 1.75-l containers (Idaho: -2.9%, Oregon: -4.9%). In the analyses of spirits prices in Washington compared to California, prices in California were 24.1% lower for 750-ml containers and 29.6% lower for 1.75-l containers. CONCLUSIONS: Our findings indicate liquor prices in Washington have increased since our 2014 assessment at a larger percentage than prices in the neighboring control states Oregon and Idaho, with varying effects on brands, container sizes, and store types. We demonstrate privatization is associated with a different pattern of prices across store types than seen in California.

Commentary: Don't Further Privatize Medicare.

The Medicare program is quietly becoming privatized through increasing enrollment in Medicare Advantage (MA) plans, even though MA has not lived up to its promise of delivering better care at lower cost. Policymakers must reverse this trend and ensure parity between traditional Medicare and MA rather than encourage it through legislation that only benefits MA. Furthermore, as discussions of expanding health insurance coverage through Medicare intensify, policymakers should explore what version of Medicare they wish to expand.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: Corporatization and the rise of private equity in dermatology.

Within the past 2 decades, for-profit financial groups have become increasingly involved in health care. Outlier dermatology practices with high volumes of well-reimbursed procedures are attractive to consolidation backed by private equity. With fewer choices for independent or group private practice, junior dermatologists are increasingly seeking employment without ownership in private equity-backed corporate groups whose primary fiscal responsibility lies with their investors. Medicare's response to corporatization and consolidation has already changed the practice of dermatopathology. Dermatologists should be aware of this history, given the ability of corporations and private equity groups to shape the present and future of our field.

Neoliberal Long-Term Care: From Community to Corporate Control.

Publicly (mainly Medicaid) funded long-term care (LTC) services have evolved from a nursing home dominated system of service to a much more balanced system including home- and community-based services (HCBS) programs over the last 30 years. The HCBS programs have been largely administered by the state and local level nonprofit aging networks (ANs) consisting of Area Agencies on Aging and thousands of service providers. Over the last decade, however, for-profit HMOs administered primarily by large insurance companies have begun to displace AN organizations. State policymakers have embraced for-profit privatizations under the rationale that this approach will generate greater savings, efficiencies, and higher quality outcomes than the traditional public or private nonprofit models of program administration. As we show here, there is very little evidence for this rationale; yet, this lack of evidence has not prevented the continuing growth of for-profit managed LTC programs supported more by an ideology of market fundamentalism than empirical evidence. We also describe six possible consequences of the trend toward corporate control of public LTC services in the years ahead.

[Social Healthcare Organizations: a phenomenological expression of healthcare privatization in Brazil]. / Organizações Sociais da Saúde: uma expressão fenomênica da privatização da saúde no Brasil.

The study analyzed the expansion of Social Healthcare Organizations (OSS in Portuguese) in Brazil from 2009 to 2014. The ten largest OSS were measured according to their budget funding and their qualifications as non-profit organizations were explored, considering evidence of their expansion and consolidation in the management and provision of health services via strategies proper to for-profit private enterprises. The study is descriptive and exploratory and was based on public-domain documents. In their relations with government, the OSS have benefited from legal loopholes and incentives and have expanded accordingly. There has been a recent trend for these organizations to simultaneously apply for status as charitable organizations, thereby ensuring multiple opportunities for fundraising and additional tax incentives, permission to invest financial surpluses in the capital market, and remunerate their boards of directors. These organizations tend to concentrate in technology-dense hospital services, with clauses concerning increasing financial transfers to the detriment of other regulatory clauses, and special contract modalities for enabling services that are absolutely strategic for the overall functioning of the Brazilian Unified National Health System. Thus, in this study, the OSS are one component of the Health Economic and Industrial Complex, acting in management, provision, and regulation of services in a scenario of intensive commodification of health and the transfer of public funds to the private sector.

A pesquisa analisou o processo de expansão das Organizações Sociais da Saúde (OSS) no Brasil durante o período de 2009-2014. Para tanto, dimensionou as dez maiores OSS segundo recursos financeiros captados, explorou suas qualificações como entidades sem fins lucrativos, tomando em conta as evidências empíricas que apontam para sua expansão e consolidação no processo de gestão e prestação de serviços de saúde via estratégias próprias de organizações privadas lucrativas. O estudo é descritivo e exploratório, e foi realizado com base em fontes documentais de domínio público. No plano das relações com o Estado, as OSS têm se beneficiado das brechas e facilidades concedidas pela lei e apresentado uma notável expansão. Evidenciou-se um movimento recente das OSS pela busca concomitante da condição de entidades filantrópicas, assegurando múltiplas oportunidades de captação de recursos e de benefícios fiscais; a possibilidade de aplicação de excedentes financeiros no mercado de capitais; e a remuneração de seus corpos diretivos. Há uma concentração em serviços hospitalares com maior densidade tecnológica; nítida predominância de cláusulas respeitantes ao incremento de repasses financeiros em detrimento de outras cláusulas regulatórias; existência de modalidades especiais de contratos com serviços-meios absolutamente estratégicos para o funcionamento geral do Sistema Único de Saúde. Portanto, neste estudo as OSS se configuram como um dos componentes do Complexo Econômico Industrial da Saúde, nas vertentes da gestão, da prestação e da regulação de serviços, em um cenário de intensiva mercantilização da saúde e de transferência de fundo público para o setor privado.

La investigación analizó el proceso de expansión de las Organizaciones Sociales de Salud (OSS) en Brasil, durante el período de 2009-2014. Para ello, se dimensionaron las diez mayores OSS, según los recursos financieros captados, exploró sus características, como entidades sin ánimo de lucro, tomando en consideración las evidencias empíricas que apuntan a su expansión y consolidación en el proceso de gestión y prestación de servicios de salud, vía estrategias propias de organizaciones privadas con ánimo de lucro. El estudio es descriptivo y exploratorio, y fue realizado en base a fuentes documentales de dominio público. En el plano de las relaciones con el Estado, las OSS se han beneficiado de las brechas y facilidades concedidas por la ley y presentado una notable expansión. Se evidenció un movimiento reciente de esas organizaciones por la búsqueda concomitante de su condición como entidades filantrópicas, asegurando múltiples oportunidades de captación de recursos y de beneficios fiscales; la posibilidad de inversión de excedentes financieros en el mercado de capitales; y la remuneración de sus cuerpos directivos. Existe una concentración en servicios hospitalarios con una mayor densidad tecnológica; nítida predominancia de cláusulas, respecto al incremento de transferencias financieras, en detrimento de otras cláusulas regulatorias; existencia de modalidades especiales de contratos con servicios-medios absolutamente estratégicos para el funcionamiento general del Sistema Único de Salud. Por tanto, en este estudio las OSS se configuran como uno de los componentes del Complejo Económico Industrial de la Salud, en las vertientes de la gestión, de la prestación y de la regulación de servicios, en un escenario de intensiva mercantilización de la salud y de transferencia de fondos públicos hacia el sector privado.

Organizações Sociais da Saúde: uma expressão fenomênica da privatização da saúde no Brasil / Social Healthcare Organizations: a phenomenological expression of healthcare privatization in Brazil / Organizaciones Sociales de la Salud: una expresión fenoménica de la privatización de la salud en Brasil

Resumo: A pesquisa analisou o processo de expansão das Organizações Sociais da Saúde (OSS) no Brasil durante o período de 2009-2014. Para tanto, dimensionou as dez maiores OSS segundo recursos financeiros captados, explorou suas qualificações como entidades sem fins lucrativos, tomando em conta as evidências empíricas que apontam para sua expansão e consolidação no processo de gestão e prestação de serviços de saúde via estratégias próprias de organizações privadas lucrativas. O estudo é descritivo e exploratório, e foi realizado com base em fontes documentais de domínio público. No plano das relações com o Estado, as OSS têm se beneficiado das brechas e facilidades concedidas pela lei e apresentado uma notável expansão. Evidenciou-se um movimento recente das OSS pela busca concomitante da condição de entidades filantrópicas, assegurando múltiplas oportunidades de captação de recursos e de benefícios fiscais; a possibilidade de aplicação de excedentes financeiros no mercado de capitais; e a remuneração de seus corpos diretivos. Há uma concentração em serviços hospitalares com maior densidade tecnológica; nítida predominância de cláusulas respeitantes ao incremento de repasses financeiros em detrimento de outras cláusulas regulatórias; existência de modalidades especiais de contratos com serviços-meios absolutamente estratégicos para o funcionamento geral do Sistema Único de Saúde. Portanto, neste estudo as OSS se configuram como um dos componentes do Complexo Econômico Industrial da Saúde, nas vertentes da gestão, da prestação e da regulação de serviços, em um cenário de intensiva mercantilização da saúde e de transferência de fundo público para o setor privado.

Abstract: The study analyzed the expansion of Social Healthcare Organizations (OSS in Portuguese) in Brazil from 2009 to 2014. The ten largest OSS were measured according to their budget funding and their qualifications as non-profit organizations were explored, considering evidence of their expansion and consolidation in the management and provision of health services via strategies proper to for-profit private enterprises. The study is descriptive and exploratory and was based on public-domain documents. In their relations with government, the OSS have benefited from legal loopholes and incentives and have expanded accordingly. There has been a recent trend for these organizations to simultaneously apply for status as charitable organizations, thereby ensuring multiple opportunities for fundraising and additional tax incentives, permission to invest financial surpluses in the capital market, and remunerate their boards of directors. These organizations tend to concentrate in technology-dense hospital services, with clauses concerning increasing financial transfers to the detriment of other regulatory clauses, and special contract modalities for enabling services that are absolutely strategic for the overall functioning of the Brazilian Unified National Health System. Thus, in this study, the OSS are one component of the Health Economic and Industrial Complex, acting in management, provision, and regulation of services in a scenario of intensive commodification of health and the transfer of public funds to the private sector.

Resumen: La investigación analizó el proceso de expansión de las Organizaciones Sociales de Salud (OSS) en Brasil, durante el período de 2009-2014. Para ello, se dimensionaron las diez mayores OSS, según los recursos financieros captados, exploró sus características, como entidades sin ánimo de lucro, tomando en consideración las evidencias empíricas que apuntan a su expansión y consolidación en el proceso de gestión y prestación de servicios de salud, vía estrategias propias de organizaciones privadas con ánimo de lucro. El estudio es descriptivo y exploratorio, y fue realizado en base a fuentes documentales de dominio público. En el plano de las relaciones con el Estado, las OSS se han beneficiado de las brechas y facilidades concedidas por la ley y presentado una notable expansión. Se evidenció un movimiento reciente de esas organizaciones por la búsqueda concomitante de su condición como entidades filantrópicas, asegurando múltiples oportunidades de captación de recursos y de beneficios fiscales; la posibilidad de inversión de excedentes financieros en el mercado de capitales; y la remuneración de sus cuerpos directivos. Existe una concentración en servicios hospitalarios con una mayor densidad tecnológica; nítida predominancia de cláusulas, respecto al incremento de transferencias financieras, en detrimento de otras cláusulas regulatorias; existencia de modalidades especiales de contratos con servicios-medios absolutamente estratégicos para el funcionamiento general del Sistema Único de Salud. Por tanto, en este estudio las OSS se configuran como uno de los componentes del Complejo Económico Industrial de la Salud, en las vertientes de la gestión, de la prestación y de la regulación de servicios, en un escenario de intensiva mercantilización de la salud y de transferencia de fondos públicos hacia el sector privado.

Financialisation in health care: An analysis of private equity fund investments in Turkey.

The 2007-2008 global financial crisis revived interest in the impacts of financial markets and actors on our social and economic life. Nevertheless, research on health care financialisation remains scant. This article presents findings from research on one modality of financial investments in health care: global private equity funds' investments in private hospitals. Adopting a political economy approach, it analyses the drivers and impacts of the upsurge of global private equity investments in the Turkish private hospital sector amid the global financial crisis. The analysis derives from review of research and archival literature, as well as six in-depth interviews held with owners/executive board directors/general managers of the largest private hospital chains in Turkey and the general partners of their PE investors. The interviewing process took place between January and November 2016. All interviews were conducted by the author in Istanbul. The findings point to a mutually reinforcing relationship between neoliberal policies and financialisation processes in health care. The article shows that neoliberal healthcare reforms, introduced under consecutive Justice and Development Party (JDP) governments in Turkey, have been important precursors of private equity investments in healthcare services. These private equity investments, in turn, intensified and broadened the process of marketisation in health care services. Four impacts are identified, through which private equity investments hasten the marketisation of health care services. These relate to the impacts of private equity investments on a) advancing the process of chain formation by large hospital groups, b) spreading financial imperatives into the operations of private hospitals c) fostering internationalisation of capital, and d) augmenting inequities in access to health care services and standards.

'Preparing ourselves to become an international organization': Thailand Tobacco Monopoly's regional and global strategies.

The Thailand Tobacco Monopoly (TTM) controlled the country's tobacco industry from its formation in the 1940s, until the government dropped restrictions on imported cigarettes in the late 1980s in response to pressure from the United States. The TTM has since competed with transnational tobacco companies (TTCs) in a semi-monopoly market in which TTCs have steadily increased their market share. Coupled with a decline in national smoking prevalence, the result of Thailand's stringent tobacco control agenda, the TTM now accounts for a diminishing share of a contracting market. In response, the monopoly has looked to regional trade liberalisation, and proximity to markets with some of the world's highest smoking rates to expand its operations. Expansion strategies have gone largely unrealised however, and the TTM effectively remains a domestic operation. Using TTM publications, market and trade reports, industry publications, tobacco industry documents and other resources, this paper analyses TTM expansion strategies, and the limited extent to which they have been achieved. This inability to expand its operations has left the monopoly potentially vulnerable to global strategies of its transnational competitors. This article is part of the special issue 'The Emergence of Asian Tobacco Companies: Implications for Global Health Governance'.

The globalisation strategies of five Asian tobacco companies: a comparative analysis and implications for global health governance.

The global tobacco industry, from the 1960s to mid 1990s, saw consolidation and eventual domination by a small number of transnational tobacco companies (TTC). This paper draws together comparative analysis of five case studies in the special issue on 'The Emergence of Asian Tobacco Companies: Implications for Global Health Governance.' The cases suggest that tobacco industry globalisation is undergoing a new phase, beginning in the late 1990s, with the adoption of global business strategies by five Asian companies. The strategies were prompted foremost by external factors, notably market liberalisation, competition from TTCs and declining domestic markets. State protection and promotion enabled the industries in Japan, South Korea and China to rationalise their operations ahead of foreign market expansion. The TTM and TTL will likely remain domestic or perhaps regional companies, JTI and KT&G have achieved TTC status, and the CNTC is poised to dwarf all existing companies. This global expansion of Asian tobacco companies will increase competition which, in turn, will intensify marketing, exert downward price pressures along the global value chain, and encourage product innovation. Global tobacco control requires fuller understanding of these emerging changes and the regulatory challenges posed by ongoing globalisation.

The spatio-temporal relationship between alcohol outlets and violence before and after privatization: A natural experiment, Seattle, Wa 2010-2013.

Alcohol-related violence is a well-documented public health concern, where various individual and community-level factors contribute to this relationship. The purpose of this study is to examine the impact of a significant policy change at the local level, which privatized liquor sales and distribution. Specifically, we explored the relationship between alcohol and violence in Seattle, WA, 2010-2013, via hierarchical spatio-temporal disease mapping models. To measure and map this complex spatio-temporal relationship at the census block group level (n=567), we examined a variety of models using integrated nested Laplace approximations and used the deviance information criterion to gauge model complexity and fit. For each additional off-premises and on-premises alcohol outlet in a given census block group, we found a significant increase of 8% and 5% for aggravated assaults and 6% and 5% for non-aggravated assaults, respectively. Lastly, our maps showed variation in the estimated relative risks across the city of Seattle.

Depoliticising the political: Market solutions and the retreat of Swedish institutional drug treatment from state management.

BACKGROUND: This article examines developments in the Swedish drug treatment services in 1982-2000 and explores the ways in which political initiatives and the state administration's management have contributed to the major privatisations of institutional drug treatment during this period. METHODS: The empirical basis for the textual analysis lies in official reports, parliamentary material and archived records from the Stockholm County Administrative Board's management of treatment facilities. RESULTS: The major privatisations of drug treatment services in the 1980s were both unintentional and unwanted and mainly arose from a lack of bureaucratic control and ideological anchorage. The privatisations were, however, reinforced by ideologically driven NPM-oriented political initiatives in the 1990s. CONCLUSION: The market-oriented treatment services have failed to fulfil the needs for diversity and availability within a publicly financed sector, which deals with unevenly informed and often socio-economically weak citizens. New management models in this field must ensure that ideological considerations are taken into account to meet politically decided goals and means.

Austeridad y privatización sanitaria en época de crisis: ¿existen diferencias entre las comunidades autónomas? / Austerity and healthcare privatization in times of crisis: are there any differences among autonomous communities?

Objetivo: Analizar las diferencias entre comunidades autónomas según sus políticas de austeridad y privatización durante la crisis. Métodos: Se analizó el cambio producido en las comunidades autónomas en tres dimensiones: la aplicación de reformas legales, la privatización sanitaria y la financiación y los recursos sanitarios, y se construyó un indicador resumen por dimensión que se representó en mapas. Resultados: El País Vasco mostró el comportamiento más claro hacia una escasa política de austeridad y privatización, al contrario que La Rioja, Madrid e lslas Baleares durante la crisis. Conclusiones: Las categorizaciones permitirán analizar el efecto mediador de la diferente intensidad de las políticas de austeridad y privatización en la relación entre la crisis y la salud en el contexto español (AU)

Objective: To analyse the differences between autonomous communities in Spain according to their policies of austerity and healthcare privatization during the economic crisis. Methods: Changes in the application of legal reforms, healthcare privatization and healthcare financing/resources in the autonomous communities were analysed, and a summary indicator of each dimension was constructed. Results: The Basque Country showed the clearest behaviour towards a weak policy of austerity and privatization, as opposed to La Rioja, Madrid, and the Balearic Islands. Conclusions: The three classifications will enable analysis of the mediating effect of policies of austerity and privatization in the relationship between the economic crisis and health in the Spanish context (AU)

[Austerity and healthcare privatization in times of crisis: are there any differences among autonomous communities?]. / Austeridad y privatización sanitaria en época de crisis: ¿existen diferencias entre las comunidades autónomas?

OBJECTIVE: To analyse the differences between autonomous communities in Spain according to their policies of austerity and healthcare privatization during the economic crisis. METHODS: Changes in the application of legal reforms, healthcare privatization and healthcare financing/resources in the autonomous communities were analysed, and a summary indicator of each dimension was constructed. RESULTS: The Basque Country showed the clearest behaviour towards a weak policy of austerity and privatization, as opposed to La Rioja, Madrid, and the Balearic Islands. CONCLUSIONS: The three classifications will enable analysis of the mediating effect of policies of austerity and privatization in the relationship between the economic crisis and health in the Spanish context.