1. Health Reform Issues TH Tulchinsky Braun SPH Jan 2004

2. 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

3. Financing Financing within national means for social benefits Adequate overall financing (>6%GNP) Shift from supply side planning to cost per capita per output 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

4. Defining 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 factor analysis in health Improve health KABP Community attitudes to health promotion Promote public health, nutrition, environment, Immunization policies

5. Management for Cost-Effectiveness Cost containment 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

6. 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;

7. 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

8. Health System Problems: World Bank 1. Misallocation of Resources: Public money is spent on interventions of dubious cost- effectiveness, e.g. bone marrow transplants for breast cancer, 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 who have better access to tertiary care services; 3. Inefficiency: Much waste in health care, in use of brand name drugs, inefficient use of health personnel and inappropriate utilization of hospital beds;

9. Typology of Financing and Administration of National Health Systems Type Financing Source Administration

10. 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

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

12. Regulatory Factors Regulate supply Regulate demand – gatekeeper, user fees Regulate price Regulate benefits Regulate method of payment Health promotion issues

13. Health and Societal Factors Differing population needs Social inequities Improve infrastructure to reduce needs Socioeconomic improvements Public social policies Health as a national and local priority Health promotion Improve KABP (knowledge, attitudes, beliefs and practices)

14. System Determinants Shift in resource allocation Technological innovations Substitution e.g. generic drugs Total Quality Management institutional and community care New vaccines, drugs, diagnostic equipment, ORS, community health workers Home care, generic drugs, nurse practitioners External accreditation, internal review systems, patient choice, continuous quality improvement

15. 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

16. 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

17. 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

18. Douglas national health insurance Financed through government Canada, Australia 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

19. 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

20. “Laws” Sutton’s law Capone’s law Roemer’s law Bunker’s law Murphy’s law

21. Basic issues Universality Equity Comprehensiveness Accessibility Portability Tax (social security) based Quality

22. 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

23. Decentralization Transfer of responsibility to lower level of gov’t Transfer of funds to provide care Monitoring of stndards

24. Devolution Transfer of gov’tal responsibility to non-gov’t organization Universities Colleges of physicians etc Accreditation by consortium of organizations e.g. medical, nursing etc.

25. Regionalization Decentralization Integration of related services Vertical integration of acute care with long term care Organizational and financial linkages

26. Prospective Payments Systems Payment before service Predictable Limits liability Defines responsibility Risk sharing Capitation DRGs

27. Balance of Services Health promotion to terminal care Spectrum of services Care depends on person or patient needs

28. Cost Restraint Gate keeper function Downsize-Upgrade Basket of services Limit liability Patient participation – user fees Private insurance

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

30. 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

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

32. Health Reforms Continuous or periodic process Economic and political factors Epidemiologic factors Public consciousness and knowledge

33. PH Professional Roles Provide evidence Regional variations Inequities – socioeconomic, ethnic, regional, urban-rural Identify new interactions, risk factors, diseases

34. Motivation/Advocacy Whistle blowing Advocacy Investigation Media Professional bodies Publication

35. 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

36. Intellectual Challenges “Think global, act local” “Think outside of the box” Think

37. Motivation Commitment Responsibility – moral, professional Professionalism Stay the course Self esteem Recognition Isolation