Prof Stiofn 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.. 70yrs24
• 60yrs50
• gt50yrs32
• 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 Financelevel of funding
  allocated to health system and fairness in
  sharing.
• Reforms strategy and implementation plans.

9
Classifications

• Main Funding Source.
• (a)   Bismarck SystemsSocial Ins/Sickness
  Fundswith well established financing (NL, Gm,
  Blg.) Bm in transition..eg from SEMASHKO.
• (b)   Beveridge Systems...General Public
  Revenuewith well established financing (UK,
  Swdn, NZ,Can.) Bv in transition.
• (c)   Mixed Group.Bev(Irl.), Bism(Fr.),
  Swz., Chn.
• (d)   PrivateUS, Jpn.
• No pure system!

10
Classifications (contd)

• Ins. Based Tax Based
• Austria Denmark
• Belg Fin
• France Icel.
• Grm Irl.
• Lux Nway
• 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 mship/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).
• Levelscompeting claims (polit)
• area allocation choices (pol/mgl/clin)
  treatments/inds
  (clins)
• SystemsPlanned (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 NLSwd.
  

16
Effective Resource Allocation

• Prospective Budgeting
• Traditionalhistorical basis (Dmk,Pol) adequate
  for allocation and cost containment
• Activity-adjustedcontrol based soc ins systems
  encouraged incr LoS (Fr,Gm)
• Case-mix adjustedactivity and
  severity(DRGs/Irl,It,Nwy)

17
Effective Resource Allocation

• Efficient Delivery
• Variations in Q,VP..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 ( Bmark,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 6.25.0
• Nwy 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
  implementedevolutionary 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,professio
  nal,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 States role.
• Decentralisation (a central tenet of HS reform
  due to widespread disillusionment with large
  centralised bcratic 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 bcratic, 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
DALE OVERALL

• Oman 1 8
• Malta 2 5
• Italy 3 2
• France 4 1
• Spain 6 7
• Japan 9 10
• Nway 18 11
• Swdn 21 23
• UK 24 18
• Irl 32 19
• S. Afr 182 175
  
  WH Report 2000

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,Nwy)
• 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
• 1984Ottawa 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.)