assignment for Magz64

Journal of Infection and Public Health (2017) 10, 258—268

REVIEW

Critical analysis and review of the literature on healthcare privatization and its association with access to medical care in Saudi Arabia

Abdulwahab A. Alkhamis ∗

College of Health Sciences, Saudi Electronic University, Saudi Arabia

Received 14 October 2016 ; received in revised form 9 February 2017; accepted 18 February 2017

KEYWORDS Privatization; Hospital privatization; Healthcare conversion; Saudi health system

Abstract This paper is a review of the literature on hospitals privatization to assess the influence of privatization on access to medical care. The results are used to complete further analysis on the situation in Saudi Arabia. Over 979 references were initially identified through a database search, and an additional 237 were included from other sources. From these sources, only 11 articles were considered for review after excluding the ineligible articles, such as those that did not meet the hospitals privatization’s definition or other exclusion criteria. There is weak evidence and low scientific validity supporting the argument that privatization could increase access to medical care. Prior to privatization, Saudi Arabia has to consider reforming its healthcare financing, including auditing and efficiency. After privatization, a policy

has to be developed to ensure that the most vulnerable groups have access to good- quality healthcare while controlling costs for care providers. © 2017 The Author. Published by Elsevier Limited on behalf of King Saud Bin Abdu- laziz University for Health Sciences. This is an open access article under the CC

BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Contents

Introduction...................................................................................................259 Material and methods ......................................................................................... 260

Results ................................................... Discussion ................................................ Conclusions ..............................................

∗ Fax: +966 1 2613502. E-mail addresses: [email protected], [email protected]

http://dx.doi.org/10.1016/j.jiph.2017.02.014 1876-0341/© 2017 The Author. Published by Elsevier Limited on beh This is an open access article under the CC BY-NC-ND license (http://

..................................................... 260

..................................................... 266 ..................................................... 267

alf of King Saud Bin Abdulaziz University for Health Sciences. creativecommons.org/licenses/by-nc-nd/4.0/).

Critical analysis and review of the literature on healthcare privatization and its association 259

Funding ..................................................................................................... 267 Competing interests ......................................................................................... 267 Ethical approval ............................................................................................. 267 References .................................................................................................. 267

I

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he incentive for the move toward privatization ay not be the same for developing and devel-

ped countries. The financial crisis was a major otive for a number of countries to opt for pri-

atization [1]. Compared with the private sector, he new liberal economic framework for the per- ormance of public offices is inefficient [2]. This iew is supported by three different theories: pub- ic choice theory, agency theory, and property rights heory. These theories have one thing in common: n emphasis on privatization helping to improve erformance and resource utilization because the bjectives, incentives, and control mechanisms of he private sector are different from those of pub- ic entities [2]. In other words, public offices fail to rovide equal, cost-effective, efficient, and qual- ty services. Furthermore, the World Bank plays

major role by supporting privatization, mainly n developing countries [3]. Most developing coun- ries, which are typically low-income countries, are ressured to privatize by the International Mone- ary Fund and the World Bank [3,4].

Saudi Arabia, a member of the Gulf Coopera- ion Council (GCC), shares characteristics with both igh-income and low-income countries [5]. Saudi rabia is considering privatization of its health- are services with the goal of improving healthcare ccess and efficiency [6]. The fall in the price of il has resulted in a reduction of oil revenues, hich are the main source for financing govern- ent expenditure. GCC countries are expected to

ace financial challenges, including that of financing heir healthcare services.

Currently in Saudi Arabia, the Ministry of Health MOH) and other government sectors such as the inistry of Defense, Ministry of the Interior, Ministry f Education, and Ministry of the National Guard re the major healthcare providers that account or approximately 80% of the total services provided ationwide. The MOH alone provides approximately 0% of all services [5]. The MOH and other gov- rnment healthcare providers deliver all curative ervices, including primary, second, and tertiary are, rehabilitation, home healthcare, and long-

erm care.

Compulsory Employment-Based Health Insurance CEBHI) was introduced in Saudi Arabia in 1999.

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n the CEBHI system, the employer shoulders the ost of medical care in the private sector. The ooperative health insurance coverage includes all ndividual employees working in private sector and heir families [7].

‘‘Privatization’’ is an ambiguous concept; it has ifferent meanings and refers to a different scope f functions or services for different people [8]. For xample, a recently published article titled ‘‘the mpact of healthcare privatization on access to sur- ical care: cholecystectomy as a model’’ [9] used ccess to cholecystectomy surgery as a means to ompare access between public and private hospi- als.

Maarse identified four types of privatization: pri- atization of health care financing, privatization f health care provision, privatization of health are management and privatization of health care nvestment [10]. Even the privatization of health are provision can have different meanings. The uropean Observatory on Health System and Poli- ies defined privatization as the ‘‘transfer of wnership and government functions from public o private bodies, which may consist of voluntary rganizations and for-profit and not-for-profit orga- izations’’ [11]. However, other authors believed hat the scope of privatization should be sufficiently ide as to include implementing a private-sector anagement style without affecting hospital own-

rship [12]. From this perspective, a public private artnership (PPP) is viewed as a form of privatiza- ion [12,13]. This stance is, however, contrary to he view of Villa and Kane, who regarded hospital wnership as essential to privatization [14]. Addi- ionally, a vast number of studies have addressed he PPP as either a form of privatization or another odel of managing healthcare facilities and con-

rolling resources. Moreover, there are misperceptions and confu-

ion about the meaning of ‘‘privatization’’ and ‘contracting’’ [14]. Privatization involves chang- ng the identity of an institute; the contracting f an institute focuses on its external relation- hips [15] or contract periods (short or long) 16]. Other studies have distinguished between

artial privatization signifies that not all assets re transferred from the government to private wnership: the government retains some of the

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ownership [11]. Still other investigations have used ‘‘privatization’’ and ‘‘equitization’’ interchange- ably; although in some cases, ‘‘equitization’’ is used to mean ‘‘privatization of assets’’ [11]. In this respect, hospital asset ownerships (land, buildings, etc.) transfers from the government to the private sector.

In addition, there is confusion in the distinc- tion between privatization and corporatization. ‘‘Corporatization’’ has been understood to signify the reorganization of a government or semi- government agency so that it is able to operate in a financially responsible way [11]. I could not identify peer-reviewed studies addressing the influ- ence of privatization on access to medical care in non-industrialized countries such as Saudi Arabia.

This article focuses on reviewing the literature concerning the influence of hospital privatization and its associations with access to medical care, which is an outcome measure of health care. The findings obtained from this review will be used to do a further analysis on the situation in Saudi Arabia with its movement toward privatizing its hospitals and increasing the participation of private health care service providers [17]. Following government efforts to reform the health-care system in Saudi Arabia, the present study has particularly high prac- tical relevance.

This article focuses on privatization as defined by one European study on health system and policies [11], including selling of publicly owned property and assets to the private sector. Following that def- inition, however, I excluded transfers to voluntary and non-profit hospitals owing to the limited role of such hospitals in GCC countries, particularly in Saudi Arabia.

The review includes studies that investigated the privatization of health services and studies that linked the privatization of health care to its access to determine the appropriate keywords for use in the literature search. Furthermore, the full elec- tronic search strategy used the Saudi Digital Library database (including Scopus, Science Direct, JSTOR, ProQuest, Wiley Online Library, and PubMed) as well as relevant articles from the World Bank, World Health Organization, United States Agency for International Development, and Google Scholar sites. The literature review strategy is detailed in the next section.

Material and methods

The literature review strategy was carried out in three stages. First, the meaning of privatization,

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A.A. Alkhamis

ith an emphasis on the privatization of health- are services, was determined. Specifically, the ollowing keywords were used: privatization; cor- oratization; hospital privatization; conversion and rivatizations; hospital corporatization; conversion f public to private hospitals; meaning of privati- ation; hospital privatization; hospital conversion; ublic hospital conversion; hospital privatization; onversion from public to for-profit hospital; and ospital ownership.

Second, the meaning of privatization of health- are services was examined with an emphasis on ccess to health care. Specifically, the following eywords were used: privatization and access to ealth care; hospital privatization and access to ealth care; and corporatization and access to ealth care.

Third, the influence of privatization in differ- nt countries was determined, and the following eywords were used: developed and developing ountries; high-income and low-income countries; ther GCC countries and Saudi Arabia. Further- ore, similar Arabic-language keywords were used hen searching with Arabic search engines. After defining privatization, my area of focus was

he process of public hospitals becoming privately wned hospitals to be in line with the movement n Saudi Arabia to go from public to private hospi- als. I excluded from my examination studies that ddressed the conversion from public to non-profit ospitals or from non-profit to for-profit hospitals; hese institutions were subject to different influ- nces and were beyond the scope of the present nvestigation. I further excluded from this study ther forms of public to private collaboration (such s PPP, contracting out public services, public and rivate health-care investment, and any forms that id not involve a change of ownership). However, I ncluded in the analysis both qualitative, quantita- ive, and mixed method studies as well as review rticles. I conducted this investigation to cover a 3-year period (2003—2016) to obtain more publi- ations.

These limitations resulted in a small number of rticles that assessed the influence of privatization n access to medical care.

esults

he literature search demonstrated that a consider-

ble number of studies addressed the privatization f health services; 979 studies were identified by eans of database searching, and an additional

37 were included using other sources. Owing to

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uplications, 750 references were removed, such s articles from non-health-care disciplines; maga- ine and newspaper articles; articles in neither the rabic nor English languages; and articles outside he search period (January 2003—November 2016). lthough the research was started in March 2016 nd ended in December 2016, I could not identify ny peer-reviewed articles in Arabic language.

Table 1 presents the details of the main stud- es associated with the privatization of health-care acilities in the context of health-care access. This tudy identified eleven (11) reports that addressed rivatization and access to medical care directly r indirectly. These studies use different meth- ds: three quantitative, one qualitative, two mixed ethods, and five review or systematic reviews. One major concern is that privatization reduces

ealth-care access for low-income individuals, ncreases the price of services, and leads to cuts n unprofitable services.

Buse et al. determined that few studies had nvestigated privatization in terms of ability to ccess available health-care services [18]; however, hat investigation failed to cite the studies that had ctually done so. Other reports have focused on the nfluence of privatization on both access to medical are and on staffing numbers, which has an indi- ect influence on patient services. One study from reece found that private for-profit hospitals had

ower nurse staffing rates than did public hospitals 19]; other investigations focused on the quality of ealth care in this regard [20]. These results are in ine with those from one study conducted in German ospitals, which found that privatization increases fficiency [21]. The rise in efficiency was due to a eduction in the labor force (except for physicians nd administrative staff) [20] or a decrease in the upply of non-clinical staff, which was supported by ther studies [21,22].

A study by Davari et al. focused on the influ- nce of privatization on health care—–not from the erspective of supply but from that of demand. he study found that privatization does not pro- ect patients from high-cost services or direct atient payments [23]. Therefore, privatization as a negative effect on poor patient access to ealth care as reported by another study [24]. he Davari et al. finding was supported by the esults of a recent study by Ramamonjiarivelo t al. This study identified the negative conse- uences of privatization, such as the termination f some services, reduced access to care among

ndigent patients, and diminished quality of care 25].

Burns et al. found variations in health-care ccess between public and private hospitals due to

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are privatization and its association 261

ifferences in their respective missions. The differ- nt missions between for-profit and public hospitals ed to different priorities with regard to prof- table and community services [26]. That finding as confirmed by Horwitz, who stated that for- rofit hospitals are driven by profits rather than the rovision of necessary services [27]. Consequently, ccess to health care may be accorded different riorities. This interpretation was supported in a tudy by Shen. Shen found that conversion made it ore likely for a hospital to close its trauma center;

uch hospitals could stop performing the full range f reproductive health services, develop new facil- ties in more affluent neighborhoods, and attempt o close facilities in poor areas [28]. Shen’s find- ng clarifies how privatization has a negative impact n health-care access, mainly through unprofitable ervices (such as trauma and psychiatric care) and he reduction of inpatient and outpatient services 28]. That result was confirmed by other studies, hich found that for-profit hospitals discontinued nprofitable outpatient services, as identified by iotrowski [29], or psychiatric and emergency ser- ices, as determined by Horwitz [27]. Villa and Kane ound that increasing the profitability of hospitals ould lead to the termination of some essential ser- ices or reduce the scope of other services [14]. rivatization prioritizes patients with minor con- itions rather than those with multiple conditions 27].

Yip and Hsiao did not study the influence f access to health care; however, they high- ighted that providing equitable access to citizens emanded a change in health care system’s direc- ion as opposed to a change in operations [30]. The uthors’ advice to the Chinese government was that t should decelerate the movement toward priva- izing health-care services [30]. The principle of ompetition in health care is different from that n other sectors [24]. Competition among health- are providers has not helped reduce costs or ncreased health-care access in the United States 24]. Other studies have found public provision o be important toward securing equity and that overnments have the responsibility of ensuring hat health services are provided to all people 31—33].

Li et al. determined that different methods of ayment could enhance access to health care [34]. owever, privatization could be a better option han discontinuing health-care services [25], and rivatization could help by providing a timelier ser-

ice and improving hospital conditions for patients 35].

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Table 1 Main studies identifying the association between hospital privatization and access to medical care.

Study title, year, and author(s)

Objectives Design Results Comments

Public hospitals in financial distress: Is privatization a strategic choice?

To assess if financial problems were the main reason for changing hospital ownership from public to private

Quantitative The study found an association between financial distress and conversion to private hospitals

The study implies that privatization is a better option if the alternative is closing public hospitals Privatization maintains access to some services rather than closing public hospitals owing to financial distress. However, the study states that the privatization is not the best option under normal circumstances because privatization could lead to low access to care for low-income groups, price increases, and low quality of care

(2015) [25] Authors:

Ramamonjiarivelo, Zo; Weech-Maldonado, Robert; Hearld, Larry; Menachemi, Nir; Epané, Josué Patien; O’Connor, Stephen

Harnessing the privatization of China’s fragmented health-care delivery

Study of the Chinese government’s move toward promoting private investment for hospitals and a discussion of how China’s health-care system would perform if hospitals were privatized

Review of China’s health-care system

Privatization leads to increased health-care expenditure with direct costs for patients. The study recommends improved accountability, reinforcing coordination across different levels of health care, and increasing public hospitals’ performance toward more cost-effective, high-quality systems

The focus is on China’s health systems and how performance and care access could change if its hospitals became privatized

(2014) [30] Authors: Yip, Winnie;

Hsiao, William

Why public health services? Experiences from profit-driven health-care reforms in Sweden

Examining the main effect of the first two phases of health-care reform in Sweden

Review and analysis of the two phases

Privatization increases inequity. It results in a shift in patient care priority. Patients with minor heath problems are prioritized instead of those with multiple health problems

Access to medical care and quality were compromised following privatization

(2014) [43] Author: Göran Dahlgren

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Assessing the impact of privatizing public hospitals in three American states: implications for universal health coverage

Analysis of the impact of privatization on different dimensions: efficiency, profitability, and community benefits

Quantitative, longitudinal

Hospital privatization increased operating margins and occupancy rates; it reduced lengths of stay

Privatization has a negative impact on increasing the cost of services and reducing access to some health services

(2013) [14] Authors: Villa, Stefano;

Kane, Nancy

Health-care financing in Iran: is privatization a good solution?

Examining whether the privatization of public hospitals is a good alternative to improving public hospital performance and outcomes

Mixed methods: a systematic literature review and quantitative survey

The study recommends against privatization

The study focuses on Iran’s health-care system of privatization rather than conversion to public ownership(2012) It recommends optimizing the use

of health-care resources [23] The current role of privatization

does not help improve efficiency or protect patients from high-cost services and direct patient payments for health-care services

Authors: Davari, M; Haycox, A; Walley, T

Privatization has a negative effect on patient access to health care

Can Questions of the Privatization and Corporatization, and the Autonomy and Accountability of Public Hospitals, Ever be Resolved?

Studying the influence of privatization and corporatization on public hospitals’ autonomy and accountability

Review The study found mixed and weak evidence

The study did not examine the influence of privatization on access to health care; however, the study is important because it recognizes that privatization is more ideological than evidence based

(2011) [11] Authors: Braithwaite, J.,

J.F. Travaglia, and A. Corbett

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Table 1 (Continued)

Study title, year, and author(s)

Objectives Design Results Comments

Privatization of health services in less-developed countries: an empirical response to the proposals of the World Bank and Wharton School

Examining an argument between academics and World Bank officials: by reducing out-of-pocket expenditures, expanded private insurance may improve access to necessary health services in less-developed countries

Multi-method design with data collection from three different sources

The study found that privatization benefits are less than those postulated by the World Bank and Wharton School

Privatization did not improve access to health services for vulnerable groups or reduce out-of-pocket expenditures for poor people

2007 [3] Authors: Waitzkin, Howard

Jasso-Aguilar, Rebeca Iriart, Celia

The privatization of health care in Europe: an eight-country analysis

Investigating the degree to which private health care is dominated by health-care providers

Review There is a movement toward privatization, but with different types of services (primary health-care hospitals, long-term care) in different countries

The study examines the effect of privatization on health-care service delivery without explicitly measuring how this impact influences access to medical care

(2006) [44] Author: Maarse, Hans

Changes in hospital performance after ownership conversions

Examining public hospitals’ performance after ownership conversion

Qualitative method

The study found no evidence that hospitals provided less care to the poor after converting from public to for-profit institutions. The study determined that conversion made it more likely that a hospital would close its trauma center regardless of whether the hospital became private, for-profit or private, non-profit. If a public hospital became sold or its ownership was transferred to private, the hospital might stop performing the full range of reproductive health services

The study is relatively old and focuses on the hospital conversion form the public to private in the United States

(2003) Also, for-profit hospitals might develop new facilities in rich neighborhoods and try to close facilities in poor areas

[28] Author: Shen, Yu-Chu

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The Impact of Healthcare Privatization on Access to Surgical Care: Cholecystectomy as a Model

Investigating the variation in access to Cholecystectomy Surgical Care between coexisting public and private providers in Riyadh, Saudi Arabia

Quantitative, cross sectional

There are variations in median durations between symptoms and surgery between public (365 days) and private providers (90 days)

The title of the article (The Impact of Healthcare Privatization on Access to Surgical Care: Cholecystectomy as a Model) does not relate to the study objectives. The paper aimed to compare variations in access to cholecystectomy surgical care between the private and public hospitals. Therefore, the study did not investigate on the impact of healthcare privatization as stated in the paper’s title

(2017) ‘‘published online:12 October 20116’’

In addition, there are variation in waiting time after ultrasound based diagnosis between public providers (125 days) and private providers (11 days)

In addition, this study did not consider the difference in people’s ability to pay and the differences of sample hospitals. The samples from the private hospitals (Dr. Suliman Al Habib Medical Group) were 3 publicly funded, 179 insured, and 70 self-paid, whereas in public hospital (King Khalid University Hospital) were 209 publicly funded, not one was insured, and only 4 self-paid

[7] Moreover, the private hospitals have significantly shorter in hospitalization (1 days versus 2 day in public) and in admission (private hospital patients are more likely to be admitted in the same day than public hospitals)

Moreover, these two hospitals are not enough to represent the population of private and public providers

Authors: Al-Jazaeri, Ayman Ghomraoui, Firas Al-Muhanna, Wejdan Saleem, Ahmed Jokhadar, Hazem Aljurf, Tareq

In addition, the samples that represent the private provider were collected from Dr. Suliman Al Habib Medical Group, a medical facility which provide health insurance for select insured people. In other words, not all insured people have access to this medical facility. This fact indicates the samples did not represent all insured population in Saudi Arabia, because according to several studies, there are variations in access to health care among insured people [5] Therefore, the study did not compare two similar sets of population in order to interpret the results based on the differences between public and private hospitals

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f p s a p o t a c e p i H NHS still faces challenges owing to the low integra- tion between such general practitioners and its own hospitals [42]. In the absence of a definite policy

1 Passive purchasing: ‘‘the government or the purchasers, for example, a health insurance organization, directly funds govern- ment or purchaser-owned and run health facilitates paying for the inputs of the production process, including infrastructure, personnel, medicines, and supplies, and equipment’’ [40].

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Discussion

There is weak evidence and low scientific valid- ity for the argument that hospital privatization could increase access to medical care. However, evaluating the influence of privatization on med- ical care access is not simple. The impact of privatization on the conversion from a public to for-profit institution cannot be isolated from the context and environment before conversion. There- fore, the weak evidence in the literature does not consider the variations among studies regard- ing the extent to which health-care providers can undertake actions without obtaining government approval. In addition, the socioeconomic, cultural and political differences among countries prohibit generalization.

Although different studies emphasized the importance of placing enough regulations to secure equity in accessing medical care regardless of the patient’s ability to pay, most studies did not define the degree to which healthcare providers are free to create innovative solutions to address changes in operations and increase their efficiency.

To be more specific, there are differences among the various studies with respect to health-care systems, manpower availability, and health policy regulations; they determine the degree to which governments support health-care access among the most vulnerable groups. For example, strict policies could enforce private hospitals to accept patients in the most vulnerable groups regardless of their abil- ity to pay or prevent private hospitals from closing unprofitable services. This indicates that govern- ment interventions and regulations could protect vulnerable groups, whereas the private sector has freedom in its operations and the decision to follow quality standards for services.

Most studies did not consider other factors that influence the demand on inpatient and outpatient hospitals, such as the local availability of public hospitals. Rundall and Lambert found this to be a factor in reducing the demand for for-profit hospi- tals [36].

The health financing systems in Saudi Arabia are still under development [5]. Saudi Arabia has not only very low bed availability but also a low uti- lization rate [5]. Consequently, public health-care providers are inefficient. For example, the bed occupancy rate for MOH hospitals were very limited at approximately 50% according to a study by The World Bank in 2009 [37]. Whereas, the occupancy

rate of developed countries such as the United States, Germany, and United Kingdom were 68.2%, 76.4%, and 76.6%, respectively [38].

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In addition, following the implementation of ompulsory employment-based health insurance or all workers in the private sector in Saudi Ara- ia, private health-care providers were unable to ope with the huge increase in demand for health- are services [39]. According to a study by Alkhamis t al. private expenditure ought to account for over 0% of total health expenditure; however, this pro- ortion was only 22% in 2009 [5].

The conversion of public hospitals to private nstitutions is not the only approach that could help audi Arabia improve the efficiency of its health- are service delivery.

There have been moves to advance strategic urchasing.1 Strategic purchasing does not only nhance service delivery; it also improves resource llocation, the overall health of a population, nd financial protection. The move from passive urchasing2 to strategic purchasing has been rec- mmended by the World Health Organization [40]. he main advantage of strategic purchasing is that

t helps link the source of funding with a predefined ervice delivery. However, strategic purchasing can- ot improve health-care delivery systems unless the ollowing parameters are determined: the type of ervice to be purchased; the type of health-care rovider (private, public, or other); the population sing the services (such as old people, children, omen, and the poor); and the payment methods

o providers [41]. The policy makers must have articulate goals and

ormulate clear mechanisms for moving towards rivatization. For example, the MOH could privatize ome of its services to reduce the burden of its huge nd overloaded services before approaching hos- itals to undergo privatization. The privatization f primary, secondary or tertiary care, rehabilita- ion, long-term care, home health-care services, nd other types of health-care service delivery annot be examined as separate elements; it is nec- ssary to consider how all these services can be roperly integrated. For example, although fam- ly doctors operate independently of the National ealth Service (NHS) in the United Kingdom, the

2 Strategic purchasing: ‘‘involves a proactive and explicit ecision-making process, with predefined outputs and outcomes ased on population needs, including the burden of diseases’’ 40].

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ritical analysis and review of the literature on hea

hat enhances patient flow among different health- ervice providers, one of the challenges for a health ystem is ensuring that hospital privatization will llow integration with other health services. The atient flow has to be smooth among differently wned health-service providers as well as between rivate and public facilities. However, these ser- ices have different needs and capabilities and may ave different goals.

onclusions

o determine the influence of privatization on ccess to medical care, it is necessary to achieve onsensus regarding the meaning of privatization. rivatization often reduces health-care access by liminating unprofitable services and increasing he cost of health services. However, the effect f privatization on medical care access cannot e isolated from a hospital’s health-care financ- ng systems, budget formats, and patient payment ethods prior to privatization. Therefore, before

ospitals undertake privatization in Saudi Arabia, t is necessary to encourage the move toward ctivity-based or performance-based budgeting. In ddition, after privatization, the main challenge ill be determining the extent to which policy mak- rs ensure that the most vulnerable groups have ccess to good-quality health care while controlling osts for care providers.

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eferences

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[3] Waitzkin H, Jasso-Aguilar R, Iriart C. Privatization of health services in less developed countries: an empirical response to the proposals of the World Bank and Wharton School. Int J Health Serv 2007;37(2):205—27.

[4] Berer M. Editorial: who has responsibility for health in a privatised health system? Reprod Health Matters 2010;18(36):4—12.

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[8] Starr P. The meaning of privatization. Yale Law Policy Rev 1988;6(1):6—41.

[9] Al-Jazaeri A, Ghomraoui F, Al-Muhanna W, Saleem A, Jokhadar H, Aljurf T. the impact of healthcare privatiza- tion on access to surgical care: cholecystectomy as a model. World J Surg 2017;41(2):394—401.

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