Tim Tenbensel Revital Gross

Introduction: Policy innovations Definition – policy innovation – a new strategy or approach to achieve health system goals Includes a variety of measures: statements e.g. proposals, legislation, incentives, structural change, monitoring/evaluation We refer to policy innovations initiated by government which have a system-wide impact 2

The questions In what ways does the mode of funding health systems (taxation or social insurance) affect: The health system objectives that innovations address? Access & equity, efficiency, quality, population health The nature of the tools for change (policy instruments) used? Christopher Hoods NATO scheme for all policy issues (N)odality (information); (A)uthority (legislation); (T)reasure (additional funding); (O)rganisation (structure) Other policy tools (changes to) responsibility for paying for health services; workforce initiatives; technology; standards & targets; research

Importance of topic Theoretical value: Although comparisons between health systems have been conducted, the implications of differences for policy innovation have not been formerly explored Our analysis will help in developing a conceptual framework for future studies on this topic Practical value: Analysis may help to indicate which innovations are less context-dependent and therefore more amenable to transfer 4

Why might we expect differences? Structure of health systems affects many parameters -(e.g. incentives to providers, costs, quality of service, service delivery, power structure); reasonable to assume it will also affect process of policy innovation Systems shape the capacity of policy actors to act - ability/power to change - different access to resources needed for change - reasonable to assume this will lead to differences in the process of policy innovation (which is a change process) Path dependency - Historical, institutional & cultural circumstances that shaped system may have similar effects on other system features including policy innovation 5

Why might we expect similarities? Objectives of access / equity, efficiency, quality and population health are not context-dependent, they are widely shared All governments have a similar range of policy instruments at their disposal Universal trends - countries learn from each other 6

Method Analysis of innovations reported by network members of the Bertelsmann Foundation Health Policy Monitor (HPM) in the years six countries chosen: Canada, New Zealand, Finland (taxation) Israel, Netherlands, Switzerland (social insurance) 196 policy innovations reported Innovations proposed by non-govt actors excluded Reports of the progress of previously reported innovations excluded Final dataset of 137 innovations (87 from tax-funded systems, 50 from social insurance funded systems) 7

Coding Health system objectives – 5 values Access and/or equity Efficiency Quality Population Health Other For both variables, cases may have more than one value for each variable Tool for change (policy instrument) – 7 values Additional Funding Legislation / regulation Payment mechanisms Organisation / structure Information / research Standards / targets Workforce / technology

Limitations The HPM database does not include all innovations in each country Member countries can only report 10 initiatives per year Reported innovations may not be representative of countrys innovations. Selection of cases is not large enough to rule out the effect of other relevant variables Political complexion of governments 5 years may not be long enough to capture variety 9

Health System Objective

Health system objectives Access (including equity), in most but many more initiatives reported in tax-funded systems Efficiency in all, but many more examples in social insurance systems Quality-related innovations prevalent in all countries Population health outcomes in most; many in NZ 12

Possible explanations Finding that social insurance systems concentrate more on efficiency is plausible (a more pressing problem?) However, tax-funded systems have greater leverage Tax-funded systems more interested in access & equity ( because they can influence this more directly?) Influence of political complexion of governments ( ) cannot be ruled out (all SI countries had centre-right govts in this period) Time period is significant (both Canada and New Zealand were highly focused on efficiency in 1990s)

Tools for change (policy instruments)

Tool for change by country

Tool for change Additional funding – mainly in tax-funded systems Changes in payment responsibility – mainly in social insurance systems Legislating - in all to varying extents Difference in systems mainly accounted for by difference between Switzerland and Canada Structural and organisational change - in all except Switzerland (but may refer to different ways of restructuring); Workforce & technology: in all countries except Switzerland Standards & targets: in all countries Information & research: in all countries except Netherlands 18

Possible explanations Additional funding & changes to payment responsibility In tax-funded systems government is responsible for services; may lead to a greater incentive to allocate extra funding. In social insurance systems providers are responsible; government can demand more with existing funding levels. Government has less control on use of funds and thus reluctant to provide extra funding. In social insurance systems governments tend to propose ways of cost-shifting to reduce government expenses In tax-funded systems, costs can only be shifted to patients 19

Possible explanations Legislation Switzerlands pervasive use of legislation, and Canadas light use of legislation are both due to particularities of federalism Switzerland: legislative process more central to co-operative policymaking between national level and cantons Canada: provinces have legislative responsibility for most health system matters Federal/provincial tensions likely to be resolved through additional funding In other countries, only a small difference in propensity to use legislation

Conclusion Type of funding appears to influence Some tools for change (not surprisingly, those related to funding and payment) Type of funding may influence Balance of health system objectives (but we cannot rule out effect of governing parties) Type of funding appears not to influence Degree of emphasis on quality Propensity to use policy instruments not related to funding