Health Systems and Reform Health Systems and Reform IssuesIssues

TH Tulchinsky, Braun SPH

November 2004

NPH chapters 11-15

New Public HealthNew Public Health

• Classical public health

• Management of health systems

New Public HealthNew Public Health

Population health analysis Control communicable diseaseSocial and physical environmentRegulate water, food, drugs,

businesses, professions, health institutions

Care of special groupsPrevent chronic diseasesNutrition

Health targetsHealth planningEpidemiology Economics of healthQuality assuranceTechnology assessmentHealth care - allocate

resources and manage health systems

AdvocacyLegislation

Health for AllHealth for All

• National political commitment• Health as a government responsibility• Universal access• Adopt international standards• Regional and social equity in access• Free choice by consumers and providers• Healthy life-style as national policy• Health promotion as policy• Law/regulations• Regulate consumers rights in health• Public information on health• Advocacy groups - public, professional

FinancingFinancing

• Financing within national means for social benefits • Adequate overall financing (>6%GNP)• Shift from supply side planning to cost per capita• Performance or output measures• Categorical grants to promote national objectives• Increase financing at national, state and local

government levels (7-9% GNP)• Health insurance as supplement• Define "basket of services" and consumer rights • Reduce acute care beds to <3.0/1,000• District health authorities with capitation funding 

Why National Health Targets?Why National Health Targets?

• Consultative process • Statement of objectives• Indicates political commitment• Asserts national leadership• Guidance for state and local governments• Promote public health e.g. fitness, nutrition,

environment, immunization, MCH policies• Promotes documentation and data bases• Example - US - Healthy People 2010

Setting National Health TargetsSetting National Health Targets

• Define leading causes of morbidity, mortality and YPLL, hospitalization with regional analysis

• Health promotion vs. treatment philosophy• Prioritization for use of available resources• Use relevant international standards• Social equity factor analysis in health• Promotes health awareness (KABP)• Community attitudes to health promotion

Management for Cost-EffectivenessManagement for Cost-Effectiveness

• Cost containment AND increased expenditures• Priorities shift• Cost-effective health initiatives• Decentralized management• National policy, monitoring and standards • Information systems/monitoring• District health profiles• Increase primary care• Increase home care, long-term beds• Increase non-admission surgery, long-term care• Health information systems• Managed care and DRGs

Participants (Stakeholders) in National Participants (Stakeholders) in National Health SystemsHealth Systems

• Government - national, state and local health authorities;

• Employers - through negotiated heath benefits for employees;

• Insurers - public, not-for-profit and private for-profit;

• Patients, clients or consumers - as individuals or groups;

•  

• Risk groups - persons with special risk factors for disease e.g age, poverty;

• Providers - hospitals, managed care plans, medical, dental, nursing, laboratories, others;

• Providers - not-for-profit provider institutions;

• For-profit institutions, individuals and groups;

• Teaching and research institutions;

Participants (Stakeholders) in National Participants (Stakeholders) in National Health SystemsHealth Systems

• Professional associations;

• Social security systems;

• The public;

• Political parties;

• Advocacy groups - age, disease, poverty or public interest groups;

• The media;

• Economies - national, regional and local;

• International health organizations and movements;

• Pharmaceutical and medical technology industries

Health System Problems: World BankHealth System Problems: World Bank

1. Misallocation of Resources: Money is spent on interventions of dubious cost-effectiveness, while highly cost-effective interventions (TB and STD management) are neglected

2. Inequity: Poor and rural populations receive less health care, while public monies go to urban and affluent groups with better access to tertiary care services

3. Inefficiency: Waste in health care, e.g. use of brand name drugs, inefficient use of health personnel and inappropriate utilization of hospital beds

4. Exploding Costs: Costs of health care are growing faster than their economies, but in low income countries the resources for health are few and poorly managed 

Source: World Bank. World Development Report, 1993

Financing of National Health SystemsFinancing of National Health Systems

Social Security – Bismarckian – Germany, Israel

Tax based NHS - Beveridge – UK

Tax based NHI - Canada

State service – Semashko – former Soviet countries

Voluntary/governmental – US, South America, Africa

Typology of National Health SystemsTypology of National Health Systems

National health service – UK, Italy, Spain, Greece, Portugal

National health insurance – Canada

Soviet (Semashko) model – former soviet countries

NHI and Sick Funds (HMOs) – Germany, Israel

Mixed – voluntary and governmental - US

Categories of ServicesCategories of Services

Institutional CarePharmaceuticals and VaccinesAmbulatory CareHome CareElderly SupportCategorical Programs

Immunization, MCHFamily planning, Mental health, TB, STDs, HIV, Screening

Community Health ActivitiesHealthy communitiesHealth promotion - risk

groups, Environment and

occupational healthNutrition and food safetySafe water supplies, Special groupsResearchProfessional education and

training

ClassicalClassical M Market Factorsarket Factors

• Supply • Demand• Competition in cost, quality • System macro-efficiency • Vertical integration • Lateral integration • System micro-efficiency • Incentives• Disincentives• Reputation

Regulatory Factors in Health ServicesRegulatory Factors in Health Services

• Regulate supply • Regulate demand – gatekeeper, user fees• Regulate price • Regulate benefits• Regulate method of payment • Health promotion issues• Accreditation of providers

Health and Societal FactorsHealth and Societal Factors

• Differing population needs e.g. age, gender, risk groups

• Social and regional inequities• Improve infrastructure to reduce needs • Socioeconomic improvements e.g. employment• Public social policies e.g. pensions, women’s rights• Health as a national and local priority• Health promotion• KABP (knowledge, attitudes, beliefs and practices)

System DeterminantsSystem Determinants

• Patient’s rights• Shift in allocation of resources e.g hospitals vs.

community care• Technological innovations e.g. new vaccines, drugs,

diagnostic tests and equipment, ORS, Substitution e.g. generic drugs

• Total Quality Management e.g. accreditation, internal review systems, continuous quality improvement

• Home care, hospice• New health roles - Nurse practitioners, community

health workers

Semashko National Health SystemsSemashko National Health Systems

• Former USSR and Soviet countries • Government financing • Strong central government planning and control• Financing by fixed norms per population• High ratio of hospital beds and medical staff; • Post 1990 reforms emphasize decentralization with

capitation and compulsory health insurance i.e. payroll taxation

Bismarckian Health InsuranceBismarckian Health Insurance

• Funded through social security e.g. Germany, Japan, France, Austria, Belgium, Switzerland, Israel

• Compulsory employer-employee tax payment to Sick Funds or through Social Security

• Germany - governments regulate Sick Funds which pay private services; strong Sick Fund and doctor's syndicates;

• Israel's Sick Funds compete as HMOs with per capita payments for mandatory basket of services

Beveridge National Health ServiceBeveridge National Health Service

• United Kingdom, Norway, Sweden, Denmark, Italy, Spain, Portugal, Greece

• Government - taxes and revenues; UK national financing; Nordic countries combine national, regional and local taxation

• Central planning, decentralized management of hospitals, GP service and public health; integrated district health systems

• Capitation financing in UK with SMR modifier

Douglas National Health InsuranceDouglas National Health Insurance

• Financed through government• Taxation based• Cost-sharing between provincial and federal

governments e.g. Saskatchewan, Manitoba• Provincial government administration • Federal government regulation • Medical services paid by fee-for-service• Hospitals on block budgets; • Reforms to regionalize and integrate services

Mixed Private/Public SystemMixed Private/Public System

• United States, Latin America (e.g Colombia), Asia (e.g Philippines) and African countries (e.g. Nigeria)

• Private insurance through employment• Public insurance through Social Security for specific

population groups (Medicare, Medicaid)• High percentage of uninsured• Strong government regulation (US)• Mixed private medical services, public and private

hospitals, state/county preventive services; • DRG payment to hospitals, managed care; extension of

Medicaid coverage

““Laws”Laws”

• Sutton’s law – follow the money• Capone’s law – you take the north, I take the south• Roemer’s law – more beds more hospitalizations• Bunker’s law – more surgeons, more surgery• Murphy’s law – that which can go wrong will go

wrong

Basic IssuesBasic Issues

• Universality• Equity – regional, social, gender, financial• Accessibility• Comprehensiveness• Portability• Tax or social security based• Adequacy of financing• Allocation of resources• Quality

DecentralizationDecentralization

• Transfer of responsibility to lower level of gov’t – Decentralization– Devolution– Diffusion– “Decapitation” i.e. lose control/equilibrium

• Transfer of funds to provide care• Guidelines and standards, i.e. performance and

outcome indicators• Monitoring and accountability

DevolutionDevolution

• Transfer of gov’tal responsibility to non-gov’t organizations

• Universities, medical academies• Colleges of physicians • Accreditation by consortium of organizations e.g.

medical, nursing etc.• Professional organizations as lobby groups

RegionalizationRegionalization

• Decentralization, devolution• Integrate of related services• Progressive patient care• Vertical integration of acute and long term care• Ambulatory and home care• Mental health • Organizational and financial linkages• Evaluation

Prospective Payments SystemsProspective Payments Systems

• Payment before service• Predictable• Limits liability• Defines responsibility• Risk sharing• Capitation• DRGs

A Comprehensive Health Services A Comprehensive Health Services Continuum: Manitoba, CanadaContinuum: Manitoba, Canada

Healthy Public PolicyPreventionPromotionProtection

CommunityOrientedServices

SupportServices

ToSeniors

Home Care

CommunityHealth Centres

ExtendedTreatment &

Long Term Care

OutpatientAmbulatory

Care

RuralCommunity

UrbanCommunity Tertiary

Rehabilitation

Palliation

HospitalsHospitalsPromotionPromotion PalliationPalliation

Balance of ServicesBalance of Services

• Health promotion to terminal care• Spectrum of services• Care depends on person or patient needs• Financing not tied to unit of service but overall

health package of services• Incentive to shift resources e.g from hospital to

ambulatory care

Cost RestraintCost Restraint

• Gate keeper function• Downsize-upgrade hospital-oriented systems• Basket of services• Categorical programs• Prospective payment• Limit liability• Patient participation – user fees• Private insurance• Pharmaceuticals and generic substitutions

Models of CareModels of Care

• Private practice• Charity services• Guilds and friendly societies • NHS• Soviet model• Sick Funds• Prepaid group practice• Health maintenance organizations

Health for AllHealth for All

• Basic primary care for all – gov’t based– Immunization– MCH– Environmental health– Nutrition

• Secondary and tertiary care via health insurance• Contradictions and imperfect models

TrendsTrends

• Down-size hospital sector• Develop PHC• Linkage between insurance and service• Define basket of services• Generic drugs• Clinical guidelines• Technology assessment

Health ReformsHealth Reforms

• Highly political• Continuous or periodic process• Economic and political factors• Epidemiologic factors• Public consciousness, knowledge, expectations,

demands• Role of media• Lobby and professional groups

PH Professional RolesPH Professional Roles

• Provide evidence• Regional variations• Inequities – socioeconomic, ethnic, regional,

urban-rural• Identify new interactions, risk factors,

diseases• Advocacy

Motivation/AdvocacyMotivation/Advocacy

• Whistle blowing• Advocacy• Investigation• Media• Professional bodies• Publication

Conventional wisdom: Famous last Conventional wisdom: Famous last wordswords

• IBM boss - will only need 5 computers world wide• Music teacher – Beethoven is hopeless as a composer• Decca records – The Beatles will never make it• Tom Lehrer – when Mozart was my age he had been

dead for 10 years

Intellectual ChallengesIntellectual Challenges

• “Think global, act local”• “Think outside of the box”• Think• Research• Publish

MotivationMotivation

• Commitment• Responsibility – moral, professional• Professionalism• Stay the course• Rewards• Self esteem• Recognition• Isolation