Prof Stiofán de Burca

Comparing Health Systems

Health System:

Encompasses all the activities whose primary purpose is to promote, restore or maintain

health.

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.

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

Health Expenditure OECD (30) 2004

Per Capita $

1. US...6102

2. Lux...5089

15.Irl.....2596

OECD...2550

16.UK...2546

29.Mex..662

30 T`key.580

Share% GDP

1.US...15.3

2.Swtz11.6

15Dmk 8.9

8.9

19 UK 8.3

26 Irl 7.1

29 Slvk5.9

30 Kor 5.6

Health Expenditure OECD (30) 2004

Public%Expd.

80+..Lx,Cz,Slv,UK,Swd,Dmk,Nwy, Icl,Jp.

70+..Irl,Fr,Gmy,NZ,Fn,It,Hgy,OECDTky,Pgl,Blg,Sp,Astr,Cn.

60+..Pld,Astrl,Nl,

50+.Swtz,Grc,Kor.

40+..Mx,US.

Drugs Public%

1. Irl...89

2.Lux..84

.. 61

29.US..24

30.Mex.12

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:2460yrs:50%>50yrs:32

Distribution of health in population… e.g. reduce inequalities to best attainable average level of

goodness

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.

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!

Classifications (contd):

Ins. Based Tax Based

Austria DenmarkBelg FinFrance Icel.Grm Irl.Lux N`way NL SwdSwz UK

In transition In transition GDR GR Isr It Tky Pgl

Sp

Classifications (contd):

Main System of Delivery.(a) Universal………….UK, Can.,Swdn NZ.,Fr

(b) Mixed…………….. +(Irl), US(ltd), Swz. Chn.

(c)Private…………….. Jpn., US.

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%)

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.

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)

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.

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)

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.

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

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)

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

Size, configuration and performance:

Distribution of specialist services? Scale and efficiency? Uncertainty of Outcomes and Volume Problem of level for analysis. EBMed and EBMgt?

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)

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

delivery bgts.

Reforms

ContextThemesChallenges

REFORMS

Change in health care policies and in the institutions through which they are

implemented…evolutionary or radical, purposive, sustained and top-down.

  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,profession

al,financial) defines parameters of feasible and sustainable health sector reform.

Context

Macro-economics:

1. GDP growth and % Health, Education, Welfare

2. In Western Europe the public service reduces capacity for private investment.

3. CEE falling revenues for Health Sector with economic restructuring.

Context

Change Drivers:

1. Epidemiological e.g. ageing population.

2. Expectations, econ. cycles and political requirements.

3. Technology Developments

4. National/ Instl. Strategies

 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.

Reorganisation

As decentralisation, (deconcentration/admin,devolution/polit and delegation), recentralisationand 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)

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)

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.)

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.)

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).

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

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)

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)

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 )

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.)