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Health Reform Issues

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Health Reform Issues TH Tulchinsky Braun SPH Jan 2004 Health for All National political commitment Health as a government responsibility Universal access Adopt ... – PowerPoint PPT presentation

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Title: Health Reform Issues


1
Health Reform Issues
  • TH Tulchinsky
  • Braun SPH
  • Jan 2004

2
Health 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

3
Financing
  • Financing within national means for social
    benefits
  • Adequate overall financing (gt6GNP)
  • Shift from supply side planning to cost per
    capita per output
  • 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 lt3.0/1,000
  • District health authorities with capitation
    funding 

4
Defining 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 factor analysis in health
  • Improve health KABP
  • Community attitudes to health promotion
  • Promote public health, nutrition, environment,
  • Immunization policies

5
Management for Cost-Effectiveness
  • Cost containment
  • 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

6
Participants (Stakeholders) in National Health
Systems
  • 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
  • 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
  •  

7
Participants (Stakeholders) in National Health
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

8
Health System Problems World Bank
  • 1. Misallocation of Resources Public money is
    spent on interventions of dubious
    cost-effectiveness, e.g. bone marrow transplants
    for breast cancer, 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 who have better access to
    tertiary care services
  • 3. Inefficiency Much waste in health care, in
    use of brand name drugs, inefficient use of
    health personnel and inappropriate utilization of
    hospital beds

9
Typology of Financing and Administration of
National Health Systems
  • Type
  • Financing Source
  • Administration

10
Categories of Services
  • Community Health Activities
  • Healthy communities
  • Health promotion, risk groups, environment and
    occupational health, nutrition and food safety,
    safe water supplies, special groups
  • Research
  • Professional education and training
  • Institutional Care
  • Pharmaceuticals and Vaccines
  • Ambulatory Care
  • Home Care
  • Elderly Support
  • Categorical Programs
  • Immunization, MCH
  • Family planning, Mental health, TB, STDs,
    HIV, Screening

11
Classical Market Factors
  • Supply
  • Demand
  • Competition in cost, quality
  • System macro-efficiency
  • Vertical integration
  • Lateral integration
  • System micro-efficiency
  • Incentives
  • Disincentives
  • Reputation

12
Regulatory Factors
  • Regulate supply
  • Regulate demand gatekeeper, user fees
  • Regulate price
  • Regulate benefits
  • Regulate method of payment
  • Health promotion issues

13
Health and Societal Factors
  • Differing population needs
  • Social inequities
  • Improve infrastructure to reduce needs
  • Socioeconomic improvements
  • Public social policies
  • Health as a national and local priority
  • Health promotion
  • Improve KABP (knowledge, attitudes, beliefs and
    practices)

14
System Determinants
  • Shift in resource allocation
  • Technological innovations
  • Substitution e.g. generic drugs
  • Total Quality Management
  • institutional and community care
  • New vaccines, drugs, diagnostic equipment,
    ORS, community health workers
  • Home care, generic drugs, nurse practitioners
  • External accreditation, internal review systems,
    patient choice, continuous quality improvement

15
Semashko 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

16
Bismarckian 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

17
Beveridge 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

18
Douglas national health insurance
  • Financed through government
  • Canada, Australia
  • 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

19
Mixed 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

20
Laws
  • Suttons law
  • Capones law
  • Roemers law
  • Bunkers law
  • Murphys law

21
Basic issues
  • Universality
  • Equity
  • Comprehensiveness
  • Accessibility
  • Portability
  • Tax (social security) based
  • Quality

22
A Comprehensive Health Services Continuum
Manitoba, Canada
Promotion
Healthy Public Policy Prevention Promotion
Protection
Hospitals
Palliation
Support Services To Seniors
Community Health Centres
Outpatient Ambulatory Care
Urban Community
Rural Community
Palliation
Tertiary
Community Oriented Services
Home Care
Extended Treatment Long Term Care
Rehabilitation
23
Decentralization
  • Transfer of responsibility to lower level of
    govt
  • Transfer of funds to provide care
  • Monitoring of stndards

24
Devolution
  • Transfer of govtal responsibility to non-govt
    organization
  • Universities
  • Colleges of physicians etc
  • Accreditation by consortium of organizations e.g.
    medical, nursing etc.

25
Regionalization
  • Decentralization
  • Integration of related services
  • Vertical integration of acute care with long term
    care
  • Organizational and financial linkages

26
Prospective Payments Systems
  • Payment before service
  • Predictable
  • Limits liability
  • Defines responsibility
  • Risk sharing
  • Capitation
  • DRGs

27
Balance of Services
  • Health promotion to terminal care
  • Spectrum of services
  • Care depends on person or patient needs

28
Cost Restraint
  • Gate keeper function
  • Downsize-Upgrade
  • Basket of services
  • Limit liability
  • Patient participation user fees
  • Private insurance

29
Models of Care
  • Private practice
  • Charity services
  • Guilds and friendly societies
  • NHS
  • Soviet model
  • Sick Funds
  • Prepaid group practice
  • Health maintenance organizations

30
Health for All
  • Basic primary care for all govt based
  • Immunization
  • MCH
  • Environmental health
  • Nutrition
  • Secondary and tertiary care via health insurance
  • Contradictions and imperfect models

31
Trends
  • Down-size hospital sector
  • Develop PHC
  • Linkage between insurance and service
  • Define basket of services
  • Generic drugs
  • Clinical guidelines
  • Technology assessment

32
Health Reforms
  • Continuous or periodic process
  • Economic and political factors
  • Epidemiologic factors
  • Public consciousness and knowledge

33
PH Professional Roles
  • Provide evidence
  • Regional variations
  • Inequities socioeconomic, ethnic, regional,
    urban-rural
  • Identify new interactions, risk factors, diseases

34
Motivation/Advocacy
  • Whistle blowing
  • Advocacy
  • Investigation
  • Media
  • Professional bodies
  • Publication

35
Famous last words
  • 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

36
Intellectual Challenges
  • Think global, act local
  • Think outside of the box
  • Think

37
Motivation
  • Commitment
  • Responsibility moral, professional
  • Professionalism
  • Stay the course
  • Self esteem
  • Recognition
  • Isolation

38
Thank You
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