Hongoro C, Kumaranayake L
Blair Research Institute, Harare, Zimbabwe and. London School of Hygiene and Tropical Medicine, UK.
Health Policy Plan. 2000 Dec;15(4):368-77. doi: 10.1093/heapol/15.4.368.
The experience of low- and middle-income countries (LMC) with respect to regulation and legislation in the health sector is in marked contrast to that of Canada and Europe. It is suggested that the degree to which regulatory mechanisms can influence private sector activity in LMC is quite low. However, there has been little work done on exploring just how, and to what extent, these regulations fail. Through the use of stakeholder interviews, this study explored the effectiveness of regulations directed at the private-for-profit sector (general practitioners, private clinics and hospitals) in Zimbabwe. The study found that there was limited and asymmetric knowledge of basic regulations among government bodies and private providers. However, there was a clear feeling that regulations are not being implemented and enforced effectively. A variety of opportunistic practices have been observed among private providers, including: practices of self-referral, where patients are sent to other services the provider has a financial interest in; over-servicing; doctor-patient collusion to collect health insurance payments; and the use of unlicensed staff in private facilities. Key factors limiting effectiveness of regulation in the health sector include the over-centralization and lack of independence of the regulatory body, the absence of legal mechanisms to control the price of care, and the lack of knowledge by patients of their rights. The study also identified a number of potential strategies for improving the current regulatory environment. For example, in order to improve monitoring, 'informal' arrangements between the centralized regulatory body and local authorities developed. There is a need to develop ways to formalize the role of these authorities. In addition, professional associations of private providers are also identified as key players through which to improve the impact of regulation among private providers. Increasing consumer access to information and knowledge is another potential way to improve information within the regulatory process as well as implementation.
低收入和中等收入国家（LMC）在卫生部门监管和立法方面的经验与加拿大和欧洲形成鲜明对比。有人认为，监管机制对低收入和中等收入国家私营部门活动的影响程度相当低。然而，关于这些监管措施究竟如何以及在多大程度上失效的研究却很少。通过对利益相关者的访谈，本研究探讨了津巴布韦针对营利性部门（全科医生、私人诊所和医院）的监管措施的有效性。研究发现，政府机构和私人提供者对基本监管规定的了解有限且不均衡。然而，人们普遍认为监管措施没有得到有效实施和执行。在私人提供者中观察到了各种投机行为，包括：自我转诊行为，即把患者送到提供者有经济利益的其他服务机构；过度服务；医患勾结骗取医疗保险金；以及在私人机构使用无执照工作人员。限制卫生部门监管有效性的关键因素包括监管机构过度集权且缺乏独立性、缺乏控制医疗价格的法律机制以及患者对自身权利缺乏了解。该研究还确定了一些改善当前监管环境的潜在策略。例如，为了加强监管，在中央监管机构和地方当局之间建立了“非正式”安排。需要制定方法使这些当局的作用正规化。此外，私人提供者的专业协会也被视为关键角色，通过它们可以提高监管措施对私人提供者的影响。增加消费者获取信息和知识的机会是改善监管过程中的信息以及执行情况的另一种潜在方式。
