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Master in Health Economics and Policy Ethics and Health (April 10-June 19, 2012)


Master in Health Economics and Policy Ethics and Health (April 10-June 19, 2012) Marc Le Menestrel Raquel Gallego – PowerPoint PPT presentation

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Title: Master in Health Economics and Policy Ethics and Health (April 10-June 19, 2012)

Master in Health Economics and PolicyEthics
and Health(April 10-June 19, 2012)
  • Marc Le Menestrel
  • Raquel Gallego

Session 1 Why the ethics debate? Managerialism
in health care systems.
  • Managerialism and value change in the public
  • Health care systems reforms since the 80s.
  • Essay What are the main threads of the health
    care reforms carried out
  • over the turn of the century? What can we learn
    from them?
  • Required reading
  • Docteur, E. Oxley, H. 2003. Health-care systems
    Lessons from the reform experience. Paris OECD,
    pp. 7-50. (http//
  • Optional reading
  • Ferlie, E. et al. 1996. (eds.) The new public
    management in action. Oxford Oxford University
    Press. Ch. 1, pp.1-29.
  • Lane, J.E. 2000. New Public Management, London
    Routledge, pp.1-15
  • Le Grand, J. Bartlett, W. 1993. (eds).
    Quasi-markets and social policy. London
    Macmillan. Ch 2-4, pp. 13-92.
  • Paris, V., M. Devaux and L. Wei. 2010, Health
    Systems Institutional Characteristics A Survey
    of 29 OECD Countries, OECD Health Working
    Papers, No. 50, OECD Publishing.
  • Pollitt, C. 1993. Managerialism and the public
    services. Oxford Blackwell. 2nd edition, pp.1-27.

1. Managerialism and value changein the public
  • 1.1. Managerialism as an ideology
  • 1.2. Dualities past/present private sector
  • 1.3. Dualities past/present public sector
  • 1.4. Exercise
  • 1.5. Doctrinal components of NPM and performance
  • assumptions

1.1. Managerialism as an ideology (I)
  • Ideology set of believes and practices assuming
    that (better?) management can effectively solve
    economic and social problems
  • Route to social progress lies through the
    achievement of continuing increases in
    economically defined productivity.
  • Productivity increases come from the application
    of ever-more sophisticated (information and
    organization) technologies.
  • Application of technologies can only be achieved
    with a labor force disciplined in accordance
    with the productivity ideal.
  • Management is the organizational function that
    plays the crucial role in achieving such
    productivity. Qualities and professionalism of
    managers are the key to business success.
  • To perform this crucial role managers must be
    granted room to maneuvre (i.e. right to
    manage) Apocalyptic role.
  • Source (Pollitt 1990)

1.1. Managerialism as an ideology (II)
  • Classic/private sector management functions
  • POSDCORB Planning, Organizing, Staffing,
    Directing, Co-ordinating, Reporting, Budgeting
    (Gulick and Urwick, 1937)
  • Public management
  • Expenditure planning and financial management
  • Procurement
  • Civil service and labour relations
  • Organization and methods
  • Audit and evaluation
  • (Source Barzelay 2001)

1.1. Managerialism as an ideology (III)
  • 1. Set of values and ideas in relation to
  • Society should have clear objectives, motivated
    workers, no red-tape, freedom of transaction
  • Best management practices are in the private
    sector, not in the public sector
  • 2. Identification of social groups
  • Better off managers, business people
  • Worse off politicians, unions, professions,
    public sector employees

1.1. Managerialism as an ideology (IV)
  • 3. Justifies behaviours and attitudes
  • Favours autonomy, confidence, individualism,
  • Downplays control, hierarchy, equality

1.2. Dualities past/present Private sector
Dimensions Traditional firm New firm
Jobs Simple Multidimensional
Roles Controlled Empowered
Values Protective Productive
Manager Supervisor Coach
Structure Hierarchies Flat
Performance Activities Results
Aptitude Training Education
Source Hammer and Champy (1993)
1.3. Dualities past/present Public sector (I)
Traditional Public Administration New Public Management
Providers orientation Monopolistic provision Compulsion Uniformity Dependency culture Users orientation Pluralistic provision Freedom of choice Organizations form diversity Self-sufficiency culture
Soruce Adapted from Ranson and Stewart (1994)
and Metcalfe (1996)
1.2. Dualities past/present Public sector (II)
Bureaucratic paradigm Post-bureaucratic paradigm
Public interest Efficiency Administration Control Specification of functions, authority and structures Justification of costs Imposition of responsibility Complying with norms and procedures Functioning of administrative systems Outcome value for citizens Quality and value Production Achieve norms acceptance Identifying mission, services, clients and impacts Value of provision Building accountability processes Focus on human resources Understanding and applying norms Identifying and solving problems Ongoing improvement of processes Separating service and control Building support for norms Widen consumer choice Facilitate collective action Provide incentives Measuring and analyzing results Learning from evaluation
Source Barzelay (1992)
Managerialism as an ideology Some references
  • Osborne and Gaebler (1992) Reinventing Government
  • Peters and Waterman (1993) In search of
  • Moore (1995) Creating public value.

ExerciseManagement models
  • Are there any differences between private sector
    and public sector management?
  • Values
  • Aims
  • Decision-making (-ers)
  • Evaluation criteria
  • Property rights
  • Responsibility/accountability rules

Management models Some authors
  • Metcalfe
  • Ranson and Stewart
  • Flynn
  • Hughes
  • Self
  • Walsh
  • Dunleavy
  • Hood

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2. Health care systems reforms since the 80s.
  • 2.1. Health care markets
  • 2.2. Health system models
  • 2.3. Health care reforms since the 80s

2.1. Health care markets (I)
  • Health markets involve agency relations between
  • Insurers P/A
  • Purchasers A/P

  • Providers P/A
  • Professionals A/P
  • Citizens P/A

2.2. Health systems models (I)
  • Institutional models of health systems
  • Reimbursement model governmental grants to
    mutualities (private insurance in Switzerland and
  • Public contract model National health insurance
    (Social security contribution in France and
  • Integrated model National health service
    (pre-90s in the UK and New Zealand, and Spain)

Reimbursement model
Public contract model
Integrated model
2.3. Health care reforms since the 80s (I)
  • Problems common to all health system models
  • Inequity of access to services, of resource
    distribution, and of health states/levels between
    groups and regions (waiting lists)
  • Increase in health expenditure without an impact
    on the population health state (pressures from
    both demand and supply sides)
  • Inefficiency variability in medical activity and
    costs poor coordination between health care
    levels (primary and specialized)

2.3. Health care reforms since the 80s (II)
  • Problems common to all health system models
  • Citizens dissatisfaction with impersonality and
    bureaucracy in service delivery
  • Third-party payer (mal)functions
  • Insurance/coverage assumption of health
    financial risk
  • Access to health services by the population
  • Agency intelligent buyer on behalf of its

2.3. Health care reforms since the 80s (III)
  • New public management
  • Purchaser/provider separation
  • Disaggregation of hierarchically integrated
    institutional structures into quasi-autonomous
    and single function- organizations (regulation,
    financing, purchasing, provision)
  • Managed competition on the basis of contracts

2.3. Health care reforms since the 80s (IV)
  • Adequacy, equity and income protection
  • Extensions to compulsory insurance systems
    (Spain, Netherlands, Ireland)
  • Macro-economic efficiency
  • Micro-economic efficiency
  • Convergence towards the public contract model

2.3. Health care reforms since the 80s (V)
  • Macro-economic efficiency measures
  • Cost containment and overall expenditure
  • Demand side cost-sharing through
  • co-payment (fixed amount for a service)
  • co-insurance (set proportion of a service cost)
  • deductibles (fixed amount to be paid for a
    service before any benefit payment is received)
  • negotiation of fees for service and
    pharmaceutical prices
  • publicly financed basic insurance

2.3. Health care reforms since the 80s (VI)
  • Macro-economic efficiency measures (contd)
  • Supply side
  • Limits to global activity volume
  • Global budgets for physicians (Germany, Belgium)
  • Global budgets for hospitals (Netherlands,
    Belgium, France, Germany)
  • Capitation payment for primary care providers

2.3. Health care reforms since the 80s (VII)
  • Micro-economic efficiency measures productivity
    and efficiency in the system
  • Switch from integrated to social insurance
    contract model (former Eastern Germany)
  • Managed competition between
  • Medical professionals (Germany, United Kingdom)
  • Pharmaceutical products (Germany, Netherlands)
  • Hospitals (Germany, United Kingdom, Netherlands)
  • Insurers or fundholders (United Kingdom and

2.3. Health care reforms since the 80s (VIII)
  • Convergence towards the public contract model
  • Reimbursement model more strict regulations and
    contracts (France, Belgium)
  • Integrated model introduction of contracts and
    disaggregation (United Kingdom)
  • Competition between public purchasers/insurers
    (United Kingdom, Netherlands)
  • Wider consumer choice (Germany, Belgium and
  • Mix financing systems (budget limits and fee for
  • Selective and informed purchasing rather than
    passive financing

Conclusions What relevance for ethics?
  • Definition of actor/function
  • Legal personality
  • Ownership
  • Regulation
  • Mecanisms of interrelation between
  • Caracteristics of the contractual relation
  • Regulation
  • Governance structure
  • Hierarchy
  • Network
  • Market
  • Dynamic context
  • Politics
  • Economy
  • Society