Prof Stiofán de Burca

1. Prof Stiofán de Burca Comparing Health Systems

2. Health System: Encompasses all the activities whose primary purpose is to promote, restore or maintain health.

3. Comparability in Measuring Performance • Ideology, System and Policy differences, Welfare States (UK,NL,Fin,Swd,NZ,Can…) • Centralist (Irl) and Devolved Systems (Gm,Sp,Blg..) • Values underpin stewardship, goals, conceptual framework and potential impact of Health System on health.

4. Comparability in Measuring Performance • Data availability • Sources and utilisation of information re development, organisation and operation of health systems and frameworks for assessing performance. • Intersectoral actions and influences e.g. education, welfare, environment. • GDP size, state of domestic economy, population health needs and implications for policy and practice

5. Health Expenditure OECD (30) 2004

6. Health Expenditure OECD (30) 2004

7. Comparability in Measuring Performance • Key variables (WHO,2000) • Environments (constitutional, political, legal, economic, social and epidemiological) • Overall level of health... DALE e.g. WHO members.. 70yrs:24 60yrs:50% >50yrs:32 • Distribution of health in population… e.g. reduce inequalities to best attainable average level of goodness

8. Comparability in Measuring Performance • Organisation and management and characteristics of service. •   Responsiveness to population expectations and client/service orientation (level and distribution) •  Distribution of Finance…level of funding allocated to health system and fairness in sharing. • Reforms strategy and implementation plans.

9. Classifications: • Main Funding Source. (a)   Bismarck Systems…Social Ins/Sickness Funds…with well established financing (NL, Gm, Blg.); Bm in transition..eg from SEMASHKO. (b)   Beveridge Systems...General Public Revenue…with well established financing (UK, Swdn, NZ,Can.); Bv in transition. (c)   Mixed Group……….Bev+(Irl.), Bism+(Fr.), Swz., Chn. (d)   Private………………US, Jpn. No pure system!

10. Classifications (contd): • Ins. Based Tax Based Austria Denmark Belg Fin France Icel. Grm Irl. Lux N`way NL Swd Swz UK In transition In transition GDR GR Isr It Tky Pgl Sp

11. Classifications (contd): Main System of Delivery. (a) Universal………….UK, Can.,Swdn NZ.,Fr (b) Mixed…………….. +(Irl), US(ltd), Swz. Chn. (c)Private…………….. Jpn., US.

12. Classifications (contd): • Patterns of Coverage (a) Entire pop (compr compuls stat ins/Austr,Fr,Lx) (priv and compuls /Blg,NL) (vol m`ship/Swz) (state ins/Grm) (b) Majority (tax based/UK 90%,Fin 80%) Exception (Irl 30%)

13. Resource Scarcity and Priority Setting Availability: • Ability of Welfare State to support universal comprehensive cover. • Cost containment, cost share. • Cost effective resource allocation and delivery interventions.

14. Resource Scarcity and Priority Setting Priority setting: • Role of values and ethical principles that underpin choices in health care e.g.utilitarian and needs –based. • Epidemiological risks and burdens (QALY & DALE). • Levels…competing claims (polit) area allocation choices (pol/mgl/clin) treatments/inds (clins) • Systems…Planned (det. priorities at macro-level) • Competitive (ptns,clins in decn procs)

15. Resource Scarcity and Priority Setting Rationing : • Necessity, effectiveness, efficacy and ind respon.(NL/ Dunning) • Human dignity, need, solidarity, cost efficiency and effect. (Swd/PPC) • Epid. based, health needs assmt., key stakeholder (UK) • Exclusion (cap treatments/Oregon) • Guideline (NZ/Core S. Cttee) Equity as key principle to guide NL+Swd.

16. Effective Resource Allocation Prospective Budgeting: • Traditional…historical basis (Dmk,Pol) adequate for allocation and cost containment • Activity-adjusted…control –based soc ins systems encouraged incr LoS (Fr,Gm) • Case-mix –adjusted…activity and severity(DRGs/Irl,It,Nwy)

17. Effective Resource Allocation Efficient Delivery: • Variations in Q,V&P..reflect diffs in prevalence of disease, cult det prefs treatm • Patterns of structural and fin incentives and client uncertainty re most appropriate treatment.

18. Effective Resource Allocation 1. Improvement Strategies: • Nat Q devt policies (Blg,Dmk,Pol,Cz) • Legal/contractual (Fr,NL,UK) • Accreditation (Fr,NL,UK,Irl) • Q indicators (PATH/WHO) • Cochrane Collaboration • Clinical performance

19. Effective Resource Allocation 2 a.Managerial: • Decentralised provider autonomy and responsiveness to purchasers and patients. 2 b. Clinicians in management • (UK,Nord) Techniques ( B`mark,BPR,Ptn Fcsd Care, QI,intl control) ( H Info Sys)

20. Effective Resource Allocation 3. Restructuring hosps: (45-75% HC Res) • Comparison of hosp data is difficult. • Maj varn in no. beds per `000 and bulk of changes 1980/94 •   Irl.: 9.5…………. 5.0 • UK: 8.1………….5.0 • Dmk: 8.1……… 5.0 • Gr : 6.2…………5.0 • N`wy: 16.5…… 3.1 • Swd: 15.1……… 6.4 • Fin:….15.5……...10.1

21. Size, configuration and performance: • Distribution of specialist services? • Scale and efficiency? • Uncertainty of Outcomes and Volume • Problem of level for analysis. • EBMed and EBMgt?

22. Public Health Care • Re-orient( Alma-Ata/WHO)..community and ind involvement; redistribution away from hosps., intersectoral approach to policy. • Integrative role of PHC. • Primary Care: patient lists/geog defined, from salary to capitation. • Personal or family lists (Irl,Dmk,It,NL,UK) • Gatekeeper to secondary Care • Direct access to Splst Care(Gm), limited (Sp,Pgl,It,Dmk)

23. Reforms: Largest role PHC... in countries with control over part or all of other delivery bgts.

24. Reforms • Context • Themes • Challenges

25. REFORMS Change in health care policies and in the institutions through which they are implemented…evolutionary or radical, purposive, sustained and top-down.

26. Context Norms and Values: 1. Solidarity (social/collective) or market –oriented goals 2. Role of state in financing and delivery, or, self-regulating associations, insurers and providers. 3.Accountability(ethical,political,legal,professional,financial) defines parameters of feasible and sustainable health sector reform.

27. Context Macro-economics: • GDP growth and % Health, Education, Welfare • In Western Europe the public service reduces capacity for private investment. 3. CEE falling revenues for Health Sector with economic restructuring.

28. Context Change Drivers: 1.Epidemiological e.g. ageing population. 2. Expectations, econ. cycles and political requirements. 3. Technology Developments 4. National/ Instl. Strategies

29. Themes 1. Changing roles of State and market in Health Care. 2. Decentralisation to lower levels of Public Service. 3. Role, choice and empowerment of patients.

30. Reorganisation As decentralisation, (deconcentration/admin, devolution/polit and delegation), recentralisation and privatisation of State`s role. • Decentralisation (a central tenet of HS reform due to widespread disillusionment with large centralised b`cratic institutions and drawbacks of poor efficacy, slow pace of change and innovation, lack of responsiveness to environmental changes affecting health care and suspect to political manipulation)

31. Reorganisation • Centralisation (H policy, strategic decisions on H resources, regulations on public safety, monitor, assess, analyse H of population and H care provision; Irl?) • Deconcentration (Poland Provincial/Municipal power v Minstl., UK Regions)

32. Reorganisation • Devolution (Swedish Councils monopoly of integrated responsibility/fin and service) • Delegation (Italy Public Enterprises, Hungary self –regulating system of H Insrs) • Privatisation (Czech, Russ Fedn H Ins v complicated and b`cratic, pressure for capital returns affects social character of health service and discriminates against sick and vulnerable; US private insurers and avoidance of adverse risk selection.)

33. Evolving role of patient • Citizen participation: Charters (UK, Poland) • Legal rights and Ombudsman (Finland) • Legislation on med contracts/rights of patients, contract law. • Complaints System (UK, Irl.)

34. Challenges • Health Status….measuring health and disease( QALY,DALE) largely determined by interaction of 4 linked factors,(genetic susceptibility, behaviour and lifestyle, SES and environmental conditions).

35. Oman 1 8 Malta 2 5 Italy 3 2 France 4 1 Spain 6 7 Japan 9 10 N`way 18 11 Sw`dn 21 23 UK 24 18 Irl 32 19 S. Afr 182 175 WH Report 2000 DALE OVERALL

36. Basic Indicators (WH Report 2006) • Total Pop., Annual Growth Rate, Dpdcy Ratio, Pop % 60+ LE Birth, Fertility Rate, Prob Dying/`000(5,15-60) Life Expectancy at Birth: • 82yrs (Japn,San Marino) • 81yrs (Swz,Austrl) • 80yrs (Can,Andra,Fr,Isrl,Nz,N`wy) • 79yrs (UK,Cyp,Fin,Grm,Grc) • 78yrs (Irl,Blg,Cba,Dnk,Pgl,US) • 36/39 (Zimb,Swazl,S.Lne)

37. Service Quality Adverse outcomes, small area variation studies (US) • 40% clin decisions different for identical complaints! • 20/30% clin care ineffective. Outcomes of increased investment (7% to 10% GDP)

38. Choice of Provider • GP (most tax-based and sick funds allow choice eg Dmk.Gm; Fin assign.) • Specialist self-refer eg NL,Gm • Hospital (Swdn, Dmk. Restricted UK contracts; Dutch attempt created problems for social soliodarity; Isr only univl ins )

39. Equity • UK/ Black Report,1980, demonstrated an association between deprivation and ill health; Can/Lalonde Report,1974. • Health field concept ie product of lifestyle, environment, human biology and Health Care WHO, H for All Strat • 1984;Ottawa Charter H Prom • 1986 Action areas: h pub pol, supp envts, str comm. action, dev psl skills and re-orient hs. Control over h dets. • Intersectoral action (WHO Healthy Cities Prog.)