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 (>6%GNP) 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 <3.0/1,000 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 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; 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;

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, women’s rights Health as a national and local priority Health promotion KABP (knowledge, attitudes, beliefs and practices)

18. System Determinants Patient’s 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” Sutton’s law – follow the money Capone’s law – you take the north, I take the south Roemer’s law – more beds more hospitalizations Bunker’s law – more surgeons, more surgery Murphy’s 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 gov’t –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 gov’tal responsibility to non-gov’t 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 Healthy Public Policy Prevention Promotion Protection Community Oriented Services Support Services To Seniors Home Care Community Health Centres Extended Treatment & Long Term Care Outpatient Ambulatory Care Rural Community Urban Community Tertiary Rehabilitation Palliation Hospitals Promotion Palliation

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 – gov’t 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