Thesis (MBA)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: The medical scheme industry of South Africa has been exposed to fundamental changes during the last decade. We have been witness to various amalgamations and scheme closures as a result of financial pressure and changes to legislation. Never before has it been more important for medical scheme administrators to become more customer focused and find solutions for medical schemes to stay viable into the future. Relationship marketing, a widely acknowledged concept, has been recognised as an appropriate tool to manage relationships and improve customer loyalty over a long-term period. A number of studies have investigated the viability of relationship marketing strategies across different industries. No such studies have however been performed for the medical scheme industry of South Africa. The study therefore aims to investigate how loyalty between medical schemes and their respective administrators is currently maintained. It further aims to determine if the medical scheme industry would benefit from relationship marketing initiatives to encourage long-term loyalty. An in-depth literature study was performed. The underlying aspects under investigation include relationship marketing, customer relationship management (CRM) and customer loyalty. It is thus important to investigate the influence of these three components on the strength of relationships and customer retention. The second phase of the study consisted of in-depth semi-structured interviews with various scheme representatives from the industry. This study is based on an exploratory case and the qualitative data was analysed using pattern finding techniques and qualitative content analysis. The study investigated the factors that have an impact on loyalty in the medical scheme industry. It was determined that relationships between administrators and medical schemes are multilevel and although relationship marketing literature indicates that key account managers are essential for the successful use of relationship based strategies, it was evident that expertise needs to extend beyond only those in key customer management positions. It is evident from the findings of this study that the medical scheme industry of South Africa could benefit hugely from correctly implemented and well researched relationship marketing strategies. This study may therefore be useful to the medical scheme industry in that it provides insight into relationship marketing in the South African context.

This thesis explores the implications of democratisation on the regulation of health care providers. It examines the reforms in relation to two regulatory policies in the pharmaceutical market of the National Health Insurance (NHI) in South Korea – the separation of prescribing and dispensing (SPD) and the pharmaceutical pricing policy – conducted in two periods – the 1980s under the authoritarian regime and the 1990s under the democratised regime. The misuse and overuse of drugs had long been recognised as a problem for the NHI, and the tight regulation of the SPD and pharmaceutical pricing as potential solutions. Democratisation seems unlikely to tighten the government’s regulation of the SPD and pharmaceutical prices. On the one hand, the Korean authoritarian regime was known as being capable of conducting top-down regulation of societal groups, and democratisation as having liberalised the government-society relationship. On the other, pharmaceutical regulation is a sophisticated and detached issue, which restricts the ability of laypeople to mobilise and exert bottom-up pressure for regulation. Nevertheless, the authoritarian government failed to tighten, and even loosened these regulations, whereas the democratised government tightened them. This thesis explains this puzzle by focusing on the features of the agenda-setting process and the articulation of policy issues therein. In the 1980s, the SPD and the pharmaceutical reimbursement pricing policy were administrative issues, discussed exclusively between bureaucrats and the central associations of health care providers, which resulted in loose regulation. In contrast, in the 1990s, reform-oriented professionals and NGOs raised these issues and put them on the political agenda, which motivated the government to conduct tighter regulation. This thesis suggests some general implications of democratisation on the politics of regulation. The hierarchical and exclusive authoritarian policy network aims to realise policy goals set by ruling elites; however, for other policy issues, societal partners can utilise this network to promote their preferred policies. Democratisation, which promotes competitive elections and political rights, allows previously excluded policy actors to participate in policy-making networks. These new actors include professionals and activists who are able to understand regulatory issues and articulate them in ways that are salient to politicians and the general public, which will motivate the government to tighten the regulation governing its traditional policy partners.

The purpose of my Master's thesis in law is to analyse the legal position which the private healthcare providers (i.e. operators of private healthcare facilities) occupy in the Czech healthcare system, particularly in the system of public health insurance. Since the private providers emerged in the Czech Republic only after the Velvet Revolution in 1989, the development of their position within the system is relatively short and unsettled. The legal regulation of the field is quite complicated, yet is the subject of strong political controversies, partly due to the generous but vaguely formulated constitutional right to free healthcare. Currently, the Parliament is in the middle of adoption of the healthcare reform of larger scale which would make changes that deserve to be examined. The thesis is composed of Introduction, three chapters and Conclusion. Each of the chapters aims on different aspect of the topic; however, they are interlinked by common legal institutes which play role in the whole thesis. First two subchapters of Chapter I are most general and introduce the possible ways of financing healthcare (public and private insurers, direct payment) and its specifics. The options of foreign citizens are also clarified. After the conclusion that the most important system in the Czech context...

Summary: The subject of this paper is providing of lege artis health care in the system of public health insurance. The aim of the thesis is to analyse the basic terminology, current legislation and its application in practice. Lex artis is in law an uncertain term, difficult to define, therefore its frequent usage should be restricted in the future. Due to the personal experience of the author there are many practical examples from the Czech health care system used in the paper. Related case law is taken into account continuously with the exception of the separately stated recent court judgment of the Constitutional Court of the Czech Republic. The study is divided into four main chapters, introduction and conclusion. The first chapter is dedicated to the concept of lege artis in detail, its terminology and relation to the current legislation. Further subchapters deal with available health care standards and their obligation. The final parts analyze the lege artis restrictions and way of its assessment. The second chapter is dedicated to the concept of public health insurance. First, the term is defined and the current law is considered. The following parts examine the issue of health insurance companies and the network of health care facilities. Chapter three presents the labor law aspects of lege artis...

V České republice se v 90. letech objevil v oblasti přeshraničního zaměstnávání pracovníků nový fenomén, a sice mezinárodní pronájem pracovní síly. Práce sumarizuje ošetření této struktury jednak v oblasti pracovněprávní a imigrační, ale zejména v oblasti daně z příjmů. Pro úplnost jsou zmíněny i aspekty související s daní z přidané hodnoty a opomenuta nejsou ani pravidla v oblasti povinného sociálního a zdravotního pojištění. Na závěr je mezinárodní pronájem pracovní síly stručně porovnán s jinými alternativami zaměstnávání pracovníků, kterými jsou přímé zaměstnání na základě uzavřené pracovní smlouvy a vyslání pracovníků v rámci poskytování služeb.

La solidarité nationale constitue un concept fondateur de l’Etat en Tunisie. Se substituant peu à peu à la solidarité familiale, ce concept est consacré textuellement dans la Constitution et dans différentes lois. La réforme en profondeur du système d’assurance maladie opérée par la loi n°2004- 71 du 02 Août 2004, donne à ce concept une nouvelle dimension et une nouvelle ampleur. Cependant, si la loi consacre un certain nombre de principes novateurs, voire révolutionnaires en matière d’assurance maladie, la prise en charge des dépenses sanitaires par la solidarité nationale se heurte à des défis énormes dans un contexte économique et sociopolitique d’un pays comme la Tunisie. La rareté des moyens financiers disponibles, les attentes différentes des acteurs concernés par la loi (administration, prestataires de soins publics et privés, syndicats, assurés sociaux…) et la résistance farouche d’un certain corporatisme constituent de réelles entraves à une véritable mise en jeu de la solidarité nationale en matière sanitaire dans le pays. La difficulté, justement, de la mise en place de la loi n°2004-71 en est la manifestation la plus frappante. Cette difficulté se manifeste à la fois dans l’établissement du volet institutionnel de la loi, mais aussi dans les modalités pratiques de la prise en charge des dépenses de santé ; modalités prévues par la loi et ses différents textes d’application. En Tunisie, si –à travers la loi n°2004-71- on est véritablement dans un contexte juridique de renouvellement de la solidarité nationale en matière sanitaire, cette solidarité trouve dans ce même contexte une bonne partie de ses limites. / The national solidarity constitutes a concept founder of the State in Tunisia. Gradually replacing the family solidarity, this concept is textually consecrated in the Constitution and in different laws. The reform of the health insurance system under the law No. 2004-71 of August 2, 2004, gives this concept a new dimension and a new width. However, if the law establishes a number of innovative principles, indeed revolutionary in matter of health insurance, the management of health expenditure by national solidarity comes up against enormous challenges in economic and socio-political context of a country like Tunisia. The scarcity of financial means available, the different waiting from the actors concerned with the law (administration, public and private health care, trade unions, insured …) and the fierce resistance of corporatism constitute real obstacles with a true setting concerned of the national solidarity in the medical matter in the country.The difficulty, precisely, of the implementation of Law No. 2004-71 is the most striking manifestations. This difficulty appears in both the establishment of the institutional shutter of the law, and also in the practical modalities of management of health expenditures; modalities envisaged by the law and its various texts of application. In Tunisia, if - through the law No. 2004-71- we are truly in a legal context for renewal of national solidarity in health’s matter, this solidarity finds in this same context a good part of his limits.

No Brasil, o sistema de saúde é composto por duas estruturas: pública, representada pelo Sistema Único de Saúde (SUS) e privada suplementar, composta por 1.268 operadoras de planos de saúde, supervisionadas pela Agência Nacional de Saúde (ANS). No entanto, as operadoras têm sido consideradas ineficientes tanto na geração de resultados financeiros quanto na prestação de serviços aos beneficiários, destacando-se a necessidade e relevância para a saúde pública ao se buscar avaliar o seu desempenho sob essas perspectivas. O objetivo do trabalho foi, para um mesmo nível de eficiência na prestação de serviços, identificar as práticas administrativas que diferenciam as operadoras de planos de saúde (OPS) financeiramente sustentáveis. Para tanto, inicialmente foi aplicada a técnica da Análise Envoltória de Dados (DEA) no intuito de identificar operadoras eficientes em transformar inputs em outputs e, a partir dos escores obtidos, selecionar duas OPS de nível de serviços semelhantes e desempenho financeiro opostos para que fossem comparadas por meio de um estudo de múltiplos casos. A análise quantitativa indicou que as OPS de medicina de grupo apresentaram maior eficiência do que as demais modalidades. Já o estudo de múltiplos casos identificou que a gestão de políticas de crédito, de captação e aplicação de recursos, o planejamento tributário, a adoção de políticas de promoção e prevenção à saúde, as formas de remuneração dos médicos e a estratégia de composição de receitas diferenciaram a OPS de melhor desempenho. / In Brazil, the health system is composed of two structures: the public represented by the Unified Health System (SUS) and private supplementary, comprising 1,268 operators of health plans supervised by the National Health Agency (ANS). However, operators have been considered inefficient, both in the generation of financial results as in the provision of services to beneficiaries, highlighting the need and relevance to public health when it comes to assessing their performance in these prospects. The goal was for the same level of efficiency in service delivery, identify management practices that differentiate the health plan operators (OPS) financially sustainable. Thus, it was initially applied to Data Envelopment Analysis (DEA) to identify carriers of efficient health plans in the processing of inputs and outputs, and the scores by selecting two of them with a similar level of service and opposite financial performance they were compared to the cases of multiple analysis. Quantitative analysis indicated that the support type operators managed showed greater efficiency than other types. The study analysis of multiple cases identified that the political credit management, finance and investments, tax planning, adoption of health promotion and prevention policies, forms of remuneration of doctors and recipe composition of strategy were practices that differentiate the operator with the best performance.

[pt] Esta dissertação investiga a presença de informação assimétrica no mercado de planos de saúde do Brasil e os principais efeitos gerados por essa assimetria de informação, conhecidos como seleção adversa e risco moral (moral hazard). A partir de dados do Suplemento Saúde da PNAD 98, são feitas análises descritivas e realizadas inferências estatísticas para avaliação tanto do risco moral quanto da seleção adversa. Na busca por um melhor entendimento do problema de seleção adversa estima-se também um modelo logístico para investigação da relação entre a condição de uma pessoa ter plano de saúde e variáveis explicativas tais como, renda, idade e auto- avaliação do estado de saúde, dentre outras. Em uma etapa subseqüente, são realizadas inferências sobre o risco moral por intermédio de dois procedimentos distintos: no primeiro, a partir da construção de um indicador de risco moral, denominado IRM, analisa-se a diferença entre o número de consultas médicas ambulatoriais realizadas por indivíduos com e sem plano de saúde levando-se em consideração o plano amostral da PNAD 98; o segundo, consiste num procedimento que tem por objetivo verificar a relação entre o fato de uma pessoa ter plano de saúde e o número de consultas médicas realizadas, por intermédio da estimação de um modelo binomial negativo com barreira (hurdle negative binomial model). / [en] The aim of this dissertation is to investigate the presence of asymmetric information in the Brazilian health insurance market and the effects that arises due to this asymmetric information: adverse selection and moral hazard. Using the data set of the Health Supplement of the Brazilian Household Sample Survey (Pesquisa Nacional por Amostra de Domicílios - PNAD) for the year 1998, descriptive analysis are produced and statistical inferences are realized to evaluate the moral hazard and adverse selection. In order to have a better perception of the adverse selection problem it is estimated a logistic model to evaluate the relation among the condition of having a health plan and independent variables such as income, age, and health self- perception. In a next step inferences related to moral hazard are realized by two different procedures: the first one, based on the construction of a moral hazard indicator, named MHI, analyses the differences between the number of physician visits for individuals who have and who have not a health plan, considering the sample design of the Health Supplement of the Brazilian Household Sample Survey. The second procedure aims to verify the relation between having a health plan and the number of physician visits by estimating a hurdle negative binomial model, which allows the elimination of some bias in the average number of physician visits.

O objetivo desta dissertação foi analisar o mercado de saúde suplementar no Brasil e avaliar as regulamentações da Agência Nacional de Saúde Suplementar – ANS, órgão regulador do setor, no contexto da teoria da informação assimétrica. Para tanto, utilizou-se a teoria da informação assimétrica através dos problemas de seleção adversa e risco moral a fim de analisar os problemas regulatórios. Também foram levantados dados e referenciais teóricos do mercado de planos de saúde no Brasil, principalmente no que se refere a sua regulação e suas implicações. A revisão bibliográfica deste trabalho indica que diversos estudos já evidenciaram a presença de assimetria de informação no mercado de saúde suplementar. A avaliação econômica de quatro resoluções normativas da ANS também corrobora para com essa evidência e explicam a presença de seleção adversa e risco moral evidenciados da literatura. Este trabalho conclui que a regulação desse mercado falhou, no que tange a redução das falhas de mercado, mais precisamente com relação com relação à assimetria de informação, onde sua presença tornou-se mais acentuadas com suas constantes intervenções, comprometendo a sustentabilidade do mercado e reduzindo o nível de bem-estar econômico. / The objective of this dissertation was to analyze the health insurance market in Brazil and evaluate the regulations of the National Health Agency - ANS, regulatory agency, in the context of the theory of asymmetric information. Therefore, we used the theory of asymmetric information through the problems of adverse selection and moral hazard in order to analyze the regulatory problems. Also data and theoretical of the health insurance market benchmarks in Brazil, especially in relation to regulation and its implications were raised. The literature review of this work indicates that several studies have demonstrated the presence of asymmetric information in the supplementary health market. The economic evaluation of four legislative resolutions ANS also corroborates with this evidence and explain the presence of adverse selection and moral hazard evidenced literature. This paper concludes that the regulation of the market has failed, as regards the reduction of market failures, specifically with respect with respect to information asymmetry, where their presence has become more pronounced with their constant interventions, compromising the sustainability of the market and reducing the level of economic welfare.

Introdução - O sistema de saúde brasileiro é composto por um segmento público universal e por um segmento privado. Grande parte da população do município de São Paulo está coberta por planos privado de saúde, porém existem poucos estudos locais explorando a influência desse fator no uso dos serviços de saúde. O estudo de unidades geográficas menores permite um melhor entendimento da realidade local. Objetivo Analisar o uso dos serviços de saúde segundo a posse de plano privado de saúde no município de São Paulo. Métodos - Estudo transversal com base nos dados obtidos no Inquérito de Saúde no Município de São Paulo de 2008. Analisamos o uso de serviços na resolução das condições agudas de saúde, no acompanhamento de doenças crônicas, no rastreamento de neoplasias e na hospitalização. Primeiro realizamos uma análise descritiva dos dados, com estimativa das prevalências. Então, verificamos a associação de cada um dos desfechos com a posse de plano privado de saúde, por meio da regressão logística múltipla, com ajuste para variáveis demográficas, socioeconômicas e da condição de saúde, estimando o Odds Ratio. Resultados As pessoas sem plano privado de saúde apresentaram maior chance de uso de serviços de urgência e emergência. As pessoas com plano apresentaram maior chance de uso de serviços ambulatoriais, de acompanhamento da hipertensão arterial sistêmica, de rastreamento de neoplasias e de hospitalização. Conclusões A posse de plano privado de saúde determinou diferenças no uso dos serviços de saúde no município de São Paulo, havendo iniquidades relacionadas às condições socioeconômicas. / Introduction The Brazilian health system is constituted by a universal public system and a private system. The city of São Paulo has a large insurance coverage but there are few local studies on the influence of this factor on health services utilization. Smaller geographic area research allows for better understanding of the local setting. Objective To analyze health services utilization according to private health insurance ownership in São Paulo. Method We performed a trans-sectional study, based on data from a health household survey performed in 2008 in São Paulo. We analyzed health services utilization in acute health issues, chronic disease followup, cancer early detection and hospitalization. We verified the association between each outcome and the ownership of private health insurance using multiple logistic regression, taking in account adjustment factors as demographic and socioeconomic characteristics and health condition. We estimated the Odds Ratio. Results People without private health insurance had bigger chances of using emergency services. People owning insurance had bigger chances of using ambulatory services and bigger chances of using services for hypertension follow-up and for cancer early detection and hospitalization. Conclusions Private health insurance ownership engendered differences in health services utilization and there are socio-economic related inequalities in São Paulo.