South African medical schemes (health insurance or medical aid) companies offer insurance to the general public in the form of a multitude of different schemes. Each scheme has its own unique range of benefits, but certain exclusions apply across the board in respect of all schemes operated by a medical aid. In this research report, I investigate the rationale and necessity, as well as some of the ethical and legal implications of numerous notable exclusions. I further make relevant recommendations with respect to their application within the legal and ethical framework of the South Africa’s Consumer Protection Act, No. 68 of 2010.

It is widely assumed that the Private Health Sector in South Africa caters only for the 16% of the population who can afford to belong to a Medical Aid. However, a number of patients who consult private general practitioners self-fund their health expenses because they do not belong to a Medical Aid. This study measured the proportion of Medical Aid as compared to the Non-Medical Aid encounters in private general practice and the nature and cost of the encounters and medical management differences between these two groups.

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The private health care market in the United Kingdom is a multi-billion pound industry whose dynamics remain largely unexamined. This is so even though the boundaries between the public and private sectors are becoming increasingly blurred, particularly in England. Given the growing importance of this sector, the policy community needs to know more about the nature of private health care in the UK, how well the private market operates and how successful have been the various attempts within it to improve value for money and health care quality, given that private health care has traditionally been seen by many citizens as unaffordable. In particular this thesis traces recent efforts by the British United Provident Association (Bupa) to reshape the UK private healthcare market. The account provided draws on the author's experience as a senior Bupa manager involved in planning and implementing such changes. The thesis describes a series of Bupa initiatives designed to change provider behaviour in pursuit of improved quality and value-for-money, and the difficulties and obstacles encountered. The latter often centred on tensions or confrontation between the insurer and professional providers that are discussed in relation to the wider literature on the social and economic organisation of health care markets. An attempt has been made to draw some general conclusions via an empirical study of the role and limitations of market-based changes within the UK private sector. The broad conclusion is that the private market in the UK exemplifies those features of health care seen throughout the developed world that create imperfect market conditions. As such the market is highly resistant to insurer initiatives that would reverse the longstanding trend for premiums to rise above the rate of inflation. It is considered unlikely given the current market structure that any insurer, including Bupa, can escape these constraints in the short term. However, Bupa has implemented some successful initiatives that suggest that longer-term incremental change is possible.

There has been a growing interest among policymakers in the potential role of physical activity (PA) as a strategy to mitigate the challenges associated with an aging population, specifically the potential pressures on the health care system presented by an increasing need and demand for long term management of chronic health conditions. In this dissertation, the relationship between PA and health service utilization among older adults and the role of PA in reducing health services utilization in this population is examined via two studies. Study 1: The purpose of Study 1 was to examine relationships between LTPA and health services utilization in a nationally representative sample of community-dwelling adults aged 50 years and older. Methods: This study involved a secondary analysis of data from the Cycle 3.1 of the Canadian Community Health Survey. The analysis was restricted to individuals aged 50 years and older, resulting in an unweighted sample of 56,652 adults (48%M; 52%F; mean age 63.5±10.2 years), stratified a priori into three age groups (50 – 64 years, 65 – 79 years, 80 years and older). Self-reported use of general physician (GP) services, specialist physician services and hospital services for the 12-month period prior to the survey were the outcomes of interest. The main independent variable of interest was self-reported LTPA for a 3-month period prior to the survey. A comprehensive set of predisposing, enabling, and health need factors associated with health services utilization were included as control variables in all analyses. Separate multiple logistic and negative binomial regression models were used to assess the association between LTPA and each dichotomous and count-based dependent variable, respectively. Bootstrap re-sampling procedures were applied in all regression analyses. Results In the 50-64 year age group, active individuals were 27% less likely to report any contact with a GP (OR=0.73; p<.001) and had 8% fewer GP consultations (IRR=0.92; p<.01) than their inactive counterparts. Among 65 to 79 year olds, active respondents were 18% less likely than their inactive counterparts to have had an overnight hospitalization in the previous 12 months (OR=0.82, p<.05). Across all age groups, higher levels of non-leisure physical activity was associated with lower health services utilization. Study 2: The purpose of Study 2 was to investigate the effects of a randomized community-based PA intervention (50+ in motion) on participants’ health service utilization and healthcare costs over a 5-year period. Methods: 50+ in motion was a randomized clinical trial comparing the effectiveness of a class-based (CB) and home-based (HB) exercise program for older adults with select chronic health conditions (hypertension, dyslipidemia, type 2 diabetes mellitus, osteoarthritis, overweight or obesity). Of the 172 participants randomized, 59 CB and 69 HB participants granted access to their administrative health data. Data pertaining to GP and specialist physician services utilization and costs as well as hospital services utilization and costs were obtained for all consenting participants from the Saskatchewan Ministry of Health for the year prior to enrolment in the 50+ in motion study through to 48-months post-randomization, for a total of 5-years of data. Independent variables including demographic characteristics, physical activity, sedentary behaviour, cardiovascular endurance, functional fitness, body composition, blood pressure, and self-reported physical and mental health status were collected directly from participants prior to randomization and then annually for 4 years. Longitudinal effects of the 50+ in motion intervention on health services utilization and healthcare costs were assessed using the generalized estimating equation (GEE) approach with covariates selected for inclusion based on methods of purposeful selection. Results: There were no significant differences in health services utilization or health care costs between the CB and HB interventions until the final year of the study when the HB group had 60% more GP visits than the CB group and were 89% less likely than the CB group to be frequent users of specialist services. There were no significant differences between the randomization groups in healthcare costs. Measures of functional fitness emphasizing lower body strength, endurance and power were more consistently associated with lower health services utilization than CV endurance, body composition or physical activity. Sedentary behavior was associated with higher hospital costs, independent of physical activity, functional fitness and health status. Overall Conclusion: Taken together, the two studies in this thesis address a significant gap in the Canadian literature and provide novel insights into the relationships between PA, health and health services utilization in older adults. While further research is needed to improve our understanding of the relationships between physical activity and sedentary behaviour, physical fitness, and health services utilization, the findings presented in this thesis suggest reducing sedentary behaviour and improving functional fitness in older adults may be as important as physical activity, if not more so, in terms of potential impact on health services utilization and health care costs. For health care professionals and policymakers at all levels, the findings highlight the advantages of a multi-pronged, interdisciplinary approach to the development of public health initiatives and interventions focused on increasing PA participation and functional fitness among older adults.

MPH, Faculty of Health Sciences, University of the Witwatersrand, 2007

Thesis (Ph.D. (Human Movement Science))--North-West University, Potchefstroom Campus, 2007.

Diss. (sammanfattning) Linköping : Univ., 2001. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst., 2004. / Härtill 5 uppsatser.

Diss. (sammanfattning) Göteborg : Göteborgs universitet, 2006. / Härtill 4 uppsatser.