Health Systems and Reform Issues

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Health Systems and Reform Issues

• TH Tulchinsky, Braun SPH
• November 2004

NPH chapters 11-15
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New Public Health

• Classical public health
• Management of health systems

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New Public Health

• Population health analysis
• Control communicable
• disease
• Social and physical
• environment
• Regulate water, food, drugs, businesses,
  professions, health institutions
• Care of special groups
• Prevent chronic diseases
• Nutrition

• Health targets
• Health planning
• Epidemiology
• Economics of health
• Quality assurance
• Technology assessment
• Health care - allocate resources and manage
  health systems
• Advocacy
• Legislation

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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

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Financing

• Financing within national means for social
  benefits
• Adequate overall financing (gt6GNP)
• 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 lt3.0/1,000
• District health authorities with capitation
  funding 

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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

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Setting 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

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Management 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

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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
•  

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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

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Health 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
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Financing 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

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Typology 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

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Categories of Services

• Institutional Care
• Pharmaceuticals and Vaccines
• Ambulatory Care
• Home Care
• Elderly Support
• Categorical Programs
• Immunization, MCH
• Family planning, Mental health, TB, STDs,
  HIV, Screening

• 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

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Classical Market Factors

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

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Regulatory 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

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Health 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, womens
  rights
• Health as a national and local priority
• Health promotion
• KABP (knowledge, attitudes, beliefs and
  practices)

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System Determinants

• Patients 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

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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

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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

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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

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Douglas 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

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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

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Laws

• Suttons law follow the money
• Capones law you take the north, I take the
  south
• Roemers law more beds more hospitalizations
• Bunkers law more surgeons, more surgery
• Murphys law that which can go wrong will go
  wrong

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Basic Issues

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

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Decentralization

• Transfer of responsibility to lower level of
  govt
• 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

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Devolution

• Transfer of govtal responsibility to non-govt
  organizations
• Universities, medical academies
• Colleges of physicians
• Accreditation by consortium of organizations e.g.
  medical, nursing etc.
• Professional organizations as lobby groups

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Regionalization

• 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

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Prospective Payments Systems

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

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A Comprehensive Health Services Continuum
Manitoba, Canada
Promotion
Palliation
Hospitals
Healthy Public Policy Prevention Promotion
Protection
Support Services To Seniors
Community Health Centres
Outpatient Ambulatory Care
Rural Community
Urban Community
Tertiary
Palliation
Community Oriented Services
Home Care
Extended Treatment Long Term Care
Rehabilitation
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Balance 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

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Cost 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

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Models of Care

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

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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

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Trends

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

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Health 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

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PH Professional Roles

• Provide evidence
• Regional variations
• Inequities socioeconomic, ethnic, regional,
  urban-rural
• Identify new interactions, risk factors,
  diseases
• Advocacy

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Motivation/Advocacy

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

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Conventional wisdom 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

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Intellectual Challenges

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

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Motivation

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

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Thank You