Public hospital
A public hospital, or government hospital, is a hospital which is government owned and is predominantly funded by the government and operates predominantly off the money that is collected from taxpayers to fund healthcare initiatives. In almost all the developed countries but the United States of America, and in most of the developing countries, this type of hospital provides medical care almost free of charge to patients, covering expenses and wages by government reimbursement.
The level of government owning the hospital may be local, municipal, state, regional, or national, and eligibility for service, not just for emergencies, may be available to non-citizen residents.
Americas
Brazil
The Brazilian health system is a mix composed of public hospitals, non-profit philanthropic hospitals, and private hospitals. The majority of the low- and medium-income population uses services provided by public hospitals run by either the state or the municipality. Since the inception of 1988 Federal Constitution, health care is a universal right for everyone living in Brazil: citizens, permanent residents, and foreigners. To provide this service, the Brazilian government created a national public health insurance system called SUS in which all publicly funded hospitals receive payments based on the number of patients and procedures performed. The construction and operation of hospitals and health clinics are also a responsibility of the government.The system provides universal coverage to all patients, including emergency care, preventive medicine, diagnostic procedures, surgeries and medicine necessary to treat their condition. However, given budget constraints, these services are often unavailable in the majority of the country with the exception of major metropolitan regions, and even in those cities access to complex procedures may be delayed because of long lines. Despite this scenario, some patients were able to successfully sue the government for full SUS coverage for procedures performed in non-public facilities.
Recently, new legislation has been enacted forbidding private hospitals to refuse treatment to patients with insufficient funds in case of life-threatening emergencies. The law also determines that the healthcare costs in this situation are to be paid by the SUS.
According to the World Health Organization, in 2014, total expenditure on health reached 8.3% of GDP, i.e. $1,318 per capita.
Canada
In Canada all hospitals are funded through Medicare, Canada's publicly funded universal health insurance system and operated by the provincial governments. Hospitals in Canada treat all Canadian citizens and permanent residents regardless of their age, income, or social status.According to the World Health Organization, in 2014, total expenditure on health reached 10.4% of GDP, i.e. $4,641 per capita.
Hospital funding in Canada follows provincial health plans and hospitals are required by law to operate within their budgets. Provincial health plans aim to cover wide area of medical services and procedures, from hospital records to nutritional care. On average physician services receive approximately 15% of provincial health funding, while hospitals get around 35%.
Even though hospitals are mostly funded by taxpayers, some hospitals, as well as medical research facilities, receive charitable donations. Besides this, there is increasing trend of privatisation of some hospital services if those services go beyond provincial health budgets. That is usually done in a form of "outsourcing". Hospitals are inclined to outsource any service that is not related to the basic patient care. That includes hospital security, maintenance of information systems, catering service, record keeping. Those services are increasingly provided by private sector. Companies like Data General, Johnson Controls, Versa are main providers of outsourced hospital services in Canada.
United States
In the United States, two thirds of all urban hospitals are non-profit. The remaining third is split between for-profit and public, public hospitals not necessarily being not-for-profit hospital corporations. The urban public hospitals are often associated with medical schools. The largest public hospital system in the U.S. is NYC Health + Hospitals.History
The safety-net role of public hospitals has evolved since the 1700s when the first U.S. public hospital sheltered and provided medical healthcare to the poor. Until the late 20th century, public hospitals represented the "poor house" that undertook social welfare roles. The "poor house" also provided secondary medical care, specifically during epidemics. For this reason, these "poor houses" were later known as "pest" houses. Following this phase was the "practitioner period" during which, the then welfare oriented urban public hospitals changed their focus to medical care and formalized nursing care. This new phase was highlighted by the private physicians providing care to patients outside their private practices into inpatient hospital settings. To put into practice the demands of the Flexner Report published in 1910, public hospitals later benefited from the best medical care technology to hire full-time staff members, instruct medical and nursing students during the "academic period". The privatization of public hospitals was often contemplated during this period and stalled once an infectious disease outbreak such as influenza in 1918, tuberculosis in the early 1900s, and the polio epidemic in the 1950s hit the U.S.. At this time, with the goal to improve people's health and welfare by allowing for effective health planning and the creation of neighborhood health centers, health policies like the Social Security Act were enacted. This was followed by Medicare and Medicaid Act in 1965 that gave poor people in the U.S., access to inpatient and outpatient medical care from public hospitals after racial segregation ended in the South. With their mandate to care for low income patients, the public hospital started engaging in leadership roles in the communities they care for since the 1980s.There was a 14% decrease in public hospitals in the United States from 2008 to 2018, compared to 4% of the total number of hospitals. In 2021 there were 965 public hospitals in the United States, compared to 5,198 hospitals total.
Repercussions of accumulated uncompensated care
In the U.S., public hospitals receive significant funding from local, state, and/or federal governments. Currently, many urban public hospitals in the U.S. playing the role of safety-net hospitals, which do not turn away the under insured and uninsured, may charge Medicaid, Medicare, and private insurers for the care of patients. Public hospitals, especially in urban areas, have a high concentration of uncompensated care and graduate medical education as compared to all other American hospitals. 23% of emergency care, 63% of burn care and 40% of trauma care are handled by public hospitals in the cities of the United States. Many public hospitals also develop programs for illness prevention with the goal of reducing the cost of care for low-income patients and the hospital, involving Community Health Needs Assessment and identifying and addressing the social, economic, environmental, and individual behavioral determinants of health.For-profit hospitals were more likely to provide profitable medical services and less likely to provide medical services that were relatively unprofitable. Government or public hospitals were more likely to offer relatively unprofitable medical services. Not-for-profit hospitals often fell in the middle between public and for-profit hospitals in the types of medical services they provided. For-profit hospitals were quicker to respond to changes in profitability of medical services than the other two types of hospitals.
Public hospitals in America are closing at a much faster rate than hospitals overall. The number of public hospitals in major suburbs declined 27% from 1996 to 2002. Much research has proven the increase in uninsured and Medicaid enrollment entwined to unmet needs for disproportionate share subsidies to be associated with the challenges faced by public hospitals to maintain their financial viability as they compete with the private sector for paying patients. Since the creation of the Affordable Care Act in 2010, 15 million of the 48 million previously uninsured receive Medicaid. It is projected that this number will grow to about 33 million by 2018. The provision of good quality ambulatory specialty care for these uninsured and Medicaid enrolled patients has particularly been a challenge for many urban public hospitals. This accounts for many factors ranging from a shortage of specialists who are more likely to practice in the more profitable sectors than in the safety-net, to the lack of clinical space. To overcome this challenge, some public hospitals have adopted disease prevention methods, the increase of specialty providers and clinics, deployment of nurse practitioners and physician assistants in specialty clinics, asynchronous electronic consultations, telehealth, the integration of Primary Care Providers in the specialty clinics, and referral by PCP's to specialists.
Asia
China
After the Cultural Revolution, public healthcare was mandatory and private hospitals became public, state run hospitals. Each person was taken care of by the community, both for their job and for their health. Medicine focused mainly on primary care and basic prevention. The reception structures corresponded to Western dispensaries or hospitals. Because of the welfare state, both hospitals and dispensaries were public. Patients did not pay for the care they receive. However, in hospitals there were differences in the quality of care between managers, their families, deserving workers and other patients. Epidemic prevention posts was set up in 1954 throughout the country and made it possible to eradicate many epidemics. Large-scale vaccination campaigns and the strengthening of medical care in impoverished rural areas made it possible to prevent many diseases. Life expectancy rose from 35 years in 1949 to 65.86 years in 1978.The 1979 reform of the health system reduced public funding for hospitals from 90% to 15%. Hospitals must be 85% self-financing. As a result, patients have to pay for their health care. Thus, many people can no longer afford to go to hospital for treatment. In 2005, 75% of the rural inhabitants and 45% of the urban inhabitants stated that they could not afford to go to hospital for economic reasons. Urbanization and the abandonment of the countryside mean that 80% of medical resources are located in cities. In 2009, health expenditure represented 4.96% of GDP, or 72.1 euros per capita. Public funding represents 24.7% of total health expenditure. In comparison, public funding in the United States is 50% and it is nearly 80% in Japan and European countries.
Since the SARS crisis in 2003, the Chinese authorities have undertaken health system reforms and health insurance revival. In 2006, the objectives of the health reform were defined as:
Since 2009, an investment plan of 850 billion yuans was devoted to this reform. In order to improve public hospitals, several recommendations were published in February 2010:
In February 2010, sixteen hospitals in sixteen cities were designated to test this comprehensive reform.
In November 2010, the Council of State Affairs encouraged the development of private institutions to pluralize the offering of care. To this end, it introduced tax and other benefits to encourage compliance with quality standards, laws and regulations. By 2018 one private hospital network had 8,000 hospitals. "American financial firms like Sequoia Capital and Morgan Stanley have invested billions of dollars" in this network.
According to the World Health Organization, in 2014, total expenditure on health in China reached 5.5% of GDP, i.e. $731 per capita.