Title: Health Reform Issues
1Health Reform Issues
- TH Tulchinsky
- Braun SPH
- Jan 2004
2Health 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
3Financing
- 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
4Defining 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
5Management 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
6Participants (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 -
7Participants (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
8Health 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
9Typology of Financing and Administration of
National Health Systems
- Type
- Financing Source
- Administration
10Categories 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
11Classical Market Factors
- Supply
- Demand
- Competition in cost, quality
- System macro-efficiency
- Vertical integration
- Lateral integration
- System micro-efficiency
- Incentives
- Disincentives
- Reputation
12Regulatory Factors
- Regulate supply
- Regulate demand gatekeeper, user fees
- Regulate price
- Regulate benefits
- Regulate method of payment
- Health promotion issues
13Health 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)
14System 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
15Semashko 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
16Bismarckian 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
17Beveridge 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
18Douglas 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
19Mixed 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
20Laws
- Suttons law
- Capones law
- Roemers law
- Bunkers law
- Murphys law
21Basic issues
- Universality
- Equity
- Comprehensiveness
- Accessibility
- Portability
- Tax (social security) based
- Quality
22A 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
23Decentralization
- Transfer of responsibility to lower level of
govt - Transfer of funds to provide care
- Monitoring of stndards
24Devolution
- Transfer of govtal responsibility to non-govt
organization - Universities
- Colleges of physicians etc
- Accreditation by consortium of organizations e.g.
medical, nursing etc.
25Regionalization
- Decentralization
- Integration of related services
- Vertical integration of acute care with long term
care - Organizational and financial linkages
26Prospective Payments Systems
- Payment before service
- Predictable
- Limits liability
- Defines responsibility
- Risk sharing
- Capitation
- DRGs
27Balance of Services
- Health promotion to terminal care
- Spectrum of services
- Care depends on person or patient needs
28Cost Restraint
- Gate keeper function
- Downsize-Upgrade
- Basket of services
- Limit liability
- Patient participation user fees
- Private insurance
29Models of Care
- Private practice
- Charity services
- Guilds and friendly societies
- NHS
- Soviet model
- Sick Funds
- Prepaid group practice
- Health maintenance organizations
30Health 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
31Trends
- Down-size hospital sector
- Develop PHC
- Linkage between insurance and service
- Define basket of services
- Generic drugs
- Clinical guidelines
- Technology assessment
32Health Reforms
- Continuous or periodic process
- Economic and political factors
- Epidemiologic factors
- Public consciousness and knowledge
33PH Professional Roles
- Provide evidence
- Regional variations
- Inequities socioeconomic, ethnic, regional,
urban-rural - Identify new interactions, risk factors, diseases
34Motivation/Advocacy
- Whistle blowing
- Advocacy
- Investigation
- Media
- Professional bodies
- Publication
35Famous 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
36Intellectual Challenges
- Think global, act local
- Think outside of the box
- Think
37Motivation
- Commitment
- Responsibility moral, professional
- Professionalism
- Stay the course
- Self esteem
- Recognition
- Isolation
38Thank You