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Health Systems and Reform Issues

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... US - Healthy People 2010 Setting ... hospitals, managed care plans, medical, dental, nursing ... and Vaccines Ambulatory Care Home Care Elderly Support ... – PowerPoint PPT presentation

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Title: Health Systems and Reform Issues


1
Health Systems and Reform Issues
  • TH Tulchinsky, Braun SPH
  • November 2004

NPH chapters 11-15
2
New Public Health
  • Classical public health
  • Management of health systems

3
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

4
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

5
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 

6
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

7
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

8
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

9
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
  •  

10
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

11
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
12
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

13
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

14
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

15
Classical Market Factors
  • Supply
  • Demand
  • Competition in cost, quality
  • System macro-efficiency
  • Vertical integration
  • Lateral integration
  • System micro-efficiency
  • Incentives
  • Disincentives
  • Reputation

16
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

17
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)

18
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

19
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

20
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

21
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

22
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

23
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

24
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

25
Basic Issues
  • Universality
  • Equity regional, social, gender, financial
  • Accessibility
  • Comprehensiveness
  • Portability
  • Tax or social security based
  • Adequacy of financing
  • Allocation of resources
  • Quality

26
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

27
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

28
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

29
Prospective Payments Systems
  • Payment before service
  • Predictable
  • Limits liability
  • Defines responsibility
  • Risk sharing
  • Capitation
  • DRGs

30
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
31
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

32
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

33
Models of Care
  • Private practice
  • Charity services
  • Guilds and friendly societies
  • NHS
  • Soviet model
  • Sick Funds
  • Prepaid group practice
  • Health maintenance organizations

34
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

35
Trends
  • Down-size hospital sector
  • Develop PHC
  • Linkage between insurance and service
  • Define basket of services
  • Generic drugs
  • Clinical guidelines
  • Technology assessment

36
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

37
PH Professional Roles
  • Provide evidence
  • Regional variations
  • Inequities socioeconomic, ethnic, regional,
    urban-rural
  • Identify new interactions, risk factors,
    diseases
  • Advocacy

38
Motivation/Advocacy
  • Whistle blowing
  • Advocacy
  • Investigation
  • Media
  • Professional bodies
  • Publication

39
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

40
Intellectual Challenges
  • Think global, act local
  • Think outside of the box
  • Think
  • Research
  • Publish

41
Motivation
  • Commitment
  • Responsibility moral, professional
  • Professionalism
  • Stay the course
  • Rewards
  • Self esteem
  • Recognition
  • Isolation

42
Thank You
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