Hans Okkels Birk, Karsten Vrangbæk, Andreas Rudkjøbing, Allan Krasnik · 7 authors
Denmark has a tradition of a decentralized health system. However, during recent years, reforms and policy initiatives have gradually centralized the health system in different ways. The structural reform of 2007 merged the old counties into fewer bigger regions, and the old municipalities likewise. The hospital structure is undergoing similar reforms, with fewer, bigger and more specialized hospitals. Furthermore, a more centralized approach to planning and regulation has been taking place over recent years. This is evident in the new national planning of medical specialties as well as the establishment of a nationwide accreditation system, the Danish Healthcare Quality Programme, which sets national standards for health system providers in Denmark. Efforts have also been made to ensure coherent patient pathways - at the moment for cancer and heart disease - that are similar nationwide. These efforts also aim at improving intersectoral cooperation. Financially, recent years have seen the introduction of a higher degree of activity-based financing in the public health sector, combined with the traditional global budgeting.A number of challenges remain in the Danish health care system. The consequences of the recent reforms and centralization initiatives are yet to be fully evaluated. Before this happens, a full overview of what future reforms should target is not possible. Denmark continues to lag behind the other Nordic countries in regards to some health indicators, such as life expectancy. A number of risk factors may be the cause of this: alcohol intake and obesity continue to be problems, whereas smoking habits are improving. The level of socioeconomic inequalities in health also continues to be a challenge. The organization of the Danish health care system will have to take a number of challenges into account in the future. These include changes in disease patterns, with an ageing population with chronic and long-term diseases; ensuring sufficient staffing; and deciding how to improve public health initiatives that target prevention of diseases and favour health improvements.
Jan Klavus, Ilkka Vohlonen, Juha Kinnunen, Veli Koistinen · 5 authors
The Finnish health care system is financed in a highly decentralized manner. In the tax-financed Beveridge model each municipality is responseble for financing and organizing health care services for its residents. This paper examined the annual incidence and treatment costs of three cost-intensive DRG-groups, and all DRG-groups together. The objective was to estimate municipal level predictions on the incidence of new illness cases and their associated costs, and to analyze whether there was greater uncertainty in anticipated specialized health care costs in municipalities with smaller populations. The dataset comprised of longitudinal hospital utilization and discharge data from Hospital Discharge Registers. The expected annual variation of illness cases and costs was assessed with respect to 95% confidence intervals estimated for each morbidity group and municipality. The results indicated that the costs of the selected morbidity groups fluctuated in a completely uncontrollable manner in municipalities with small populations. As the median size of Finnish municipalities is less than 6000, the inability to anticipate periodic health care costs constitutes an extensive financial problem and calls for the establishment of larger regional units and funding pools.
José Jesús Martín Martín, María del Puerto López del Amo González
The Spanish National Health System (SNHS) has sustainability problems resulting from weaknesses in institutional design and governance compounded by the economic crisis it faces. The global economic crisis has had a particularly virulent impact in Spain, characterized by high levels of unemployment and public and private debt. Fiscal adjustment policies implemented may significantly compromise the SNHS. Along with general funding problems, the strong territorial decentralization of health jurisdictions in the Autonomous Communities has not been backed up by efficient State-level health coordination. The SNHS suffers from problems in its rules of governance, its autonomous financing system, human resource policies and diversity of direct and indirect management models in different Autonomous Communities. A reform strategy in Spanish healthcare governancemust be articulated within the context of a broader review of public policies to stabilize the lines of defense of the welfare state. Within the scope of the health sector, the financing system must be improved and institutional changes to increase efficiency must be implemented.
Health care is widely considered to be an important determinant of health. The health care systems of Western Europe have recently experienced significant reforms, under pressure from economic globalization. Similarly, in Eastern Europe, health care reforms have been undertaken in response to the demands of the new market economy. Both of these changes may influence equality in health outcomes. This article aims to identify the mechanisms through which health care may affect inequalities. The authors conducted a literature review of the effects on health inequalities of European health care reforms. Particular reference was paid to interventions in the fields of financing and pooling, allocation, purchasing, and provision of services. The majority of studies were from Western Europe, and the outcomes most often examined were access to services or income distribution. Overall, the quality of research was poor, confirming the need to develop an appropriate impact assessment methodology. Few studies were related to pooling, allocation, or purchasing. For financing and purchasing, the studies showed that publicly funded universal health care reduces the impact of ill health on income distribution, while insurance systems can increase inequalities in access to care. Out-of-pocket payments increase inequalities in access to care and contribute to impoverishment. Decentralizing health services can lead to geographic inequalities in health care access. Nationalized, publicly funded health care systems are most effective at reducing inequalities in access and reducing the effects on health of income distribution.
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Anna Sagan, Dimitra Panteli, W Borkowski, M Dmowski · 31 authors
Since the successful transition to a freely elected parliament and a market economy after 1989, Poland is now a stable democracy and is well represented within political and economic organizations in Europe and worldwide. The strongly centralized health system based on the Semashko model was replaced with a decentralized system of mandatory health insurance, complemented with financing from state and territorial self-government budgets. There is a clear separation of health care financing and provision: the National Health Fund (NFZ) the sole payer in the system is in charge of health care financing and contracts with public and non-public health care providers. The Ministry of Health is the key policy-maker and regulator in the system and is supported by a number of advisory bodies, some of them recently established. Health insurance contributions, borne entirely by employees, are collected by intermediary institutions and are pooled by the NFZ and distributed between the 16 regional NFZ branches. In 2009, Poland spent 7.4% of its gross domestic product (GDP) on health. Around 70% of health expenditure came from public sources and over 83.5% of this expenditure can be attributed to the (near) universal health insurance. The relatively high share of private expenditure is mostly represented by out-of-pocket (OOP) payments, mainly in the form of co-payments and informal payments. Voluntary health insurance (VHI) does not play an important role and is largely limited to medical subscription packages offered by employers. Compulsory health insurance covers 98% of the population and guarantees access to a broad range of health services. However, the limited financial resources of the NFZ mean that broad entitlements guaranteed on paper are not always available. Health care financing is overall at most proportional: while financing from health care contributions is proportional and budgetary subsidies to system funding are progressive, high OOP expenditures, particularly in areas such as pharmaceuticals, are highly regressive. The health status of the Polish population has improved substantially, with average life expectancy at birth reaching 80.2 years for women and 71.6 years for men in 2009. However, there is still a vast gap in life expectancy between Poland and the western European Union (EU) countries and between life expectancy overall and the expected number of years without illness or disability. Given its modest financial, human and material health care resources and the corresponding outcomes, the overall financial efficiency of the Polish system is satisfactory. Both allocative and technical efficiency leave room for improvement. Several measures, such as prioritizing primary care and adopting new payment mechanisms such as diagnosis-related groups (DRGs), have been introduced in recent years but need to be expanded to other areas and intensified. Additionally, numerous initiatives to enhance quality control and build the required expertise and evidence base for the system are also in place. These could improve general satisfaction with the system, which is not particularly high. Limited resources, a general aversion to cost-sharing stemming from a long experience with broad public coverage and shortages in health workforce need to be addressed before better outcomes can be achieved by the system. Increased cooperation between various bodies within the health and social care sectors would also contribute in this direction. The HiT profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services, and the role of the main actors in health systems; they describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis.
Open access
Global Health Care Issues
Healthcare Policy and Management
Health Systems, Economic Evaluations, Quality of Life
This paper is part ofa research program supported by the Health Research Institute for Health Security, with the objectives to monitor and evaluate the efficiency of health subdistrict offices in Thailand. Cost efficiency was empirically investigated based on primary surveyed data comprising 246 units operated in 12 provinces. First, descriptive statistics related to outputs (4 variables) and cost (3 variables inclusive of wages and salaries, compensation to officers, and operating expenses) are presented and discussed. All revenue and expense figures refer to fiscal year 2008. Two types of efficiency models (namely SCF and DEA) based an the input-orientation approach were applied to estimate the efficiency scores. We found that 45 units lied on the cost frontier and that represented 18 percent of the total units; in most cases, efficiency scores (DEA, VRS assumption) ranged from 0.60 to 0.75 and averaged to 0.69-implying that there was an ample room for cost-saving, specifically 31 percent, ifoutput slack or excess input were eliminated thus implying the scope for management improvement. Our estimates should be considered preliminary and an in-depth investigation needs to be taken in order further to understand the special circumstances and uncontrollable factors that might have affected the higher cost to those units, but our models failed to take note. The last section discusses policy implications and the health decentralization program in Thailand, which is a topic of policy interest. Improving the efficiency ofpublic agencies and effective public service delivery are among the goals of Thailand's public sector reform. Over the past decade, devolution of responsibilites from central agencies to local govemment units have fairly succeeded in areas of public infrastructure and social welfare-but have been less successful in primary education, public health, and environmental regulation. The transfer of the health subdistrict office is high on the national agenda, and the National Decentralization Committee strongly endorses this connection, it is important to disseminate information related to health subdistrict management, budgeting, and financing to the public, especially local administrators.
This article addresses several issues pertinent to health systems governance for health equity. It argues the importance of health systems using measures of positive health (well-being), discriminating in favour of historically less advantaged groups and weighing the costs of health care against investments in the social determinants of health. It cautions that the concept of governance could weaken the role of government, with disequalizing effects, while emphasizing the importance of two elements of good governance (transparency and participation) in health systems decision-making. It distinguishes between participation as volunteer labour and participation as exercising political rights, and questions the assumption that decentralization in health systems is necessarily empowering. It then identifies five health system roles to address issues of equity (educator/watchdog, resource broker, community developer, partnership developer and advocate/catalyst) and the implications of these roles for practice. Drawing on preliminary findings of a global research project on comprehensive primary health care, it discusses political aspects of progressive health system reform and the implications of equity-focused health system governance on health workers' roles, noting the importance of health workers claiming their identity as citizens. The article concludes with a commentary on the inherently political nature of health reforms based on equity; the necessary confrontation with power relations politics involves; and the health systems governance challenge of managing competing health discourses of efficiency and results-based financing, on the one hand, and equity and citizen empowerment, on the other.
A persistent headache is a symptom, but the underlying cause can be anything from a migraine to a brain tumor. Good medicine means identifying and treating the cause as well as the symptom. The same is true in health care reform.
Though most Americans are satisfied with their own health care, they also see the need for substantial reform. Unfortunately, the well-meaning plans currently presented to Congress are the wrong therapy because they mistake the symptoms for the underlying disease. Nearly everyone agrees on the symptoms: rapidly growing health expenditures, diminished access to affordable insurance causing many to be uninsured, and inadequate quality and outcomes for the dollars spent. But what are the root causes? While there are many contributing factors, three merit special attention.
First, there is our inefficient and inequitable system of tax-advantaged, employer-based health insurance. While the federal tax code promotes overspending by making the majority unaware of the true cost of their insurance and care, the code is grossly unfair to the self-employed, small businesses, workers who stick with a bad job because they need the coverage, and workers who lose their jobs after getting sick.
This employer-based system arose not by thoughtful design but as an unforeseen result of price controls during World War II and subsequent tax policy. How this developed and persisted despite its unfairness and maladaptive consequences is a powerful illustration of the law of unintended consequences and the fact that government can take six decades or more to fix its obvious mistakes.
Second, in health care as in other markets, real progress depends on innovation. Yet health care markets rarely conduct successful experiments with new ways of paying for and organizing health care delivery. Why? Although health care markets have some unique attributes, these are not the explanation for lack of successful innovation. Rather, health insurance markets suffer from overregulation, which limits innovation in both insurance and new ways of delivering medical care.
Third, we have Medicaid and Medicare. These enormous federal programs address critical needs by delivering health care to the poor, the disabled, and the elderly. These programs pay providers by administrative pricing formulas that are well documented to promote both overuse and underuse of appropriate care, have led to rising expenditures decoupled from better health, and obligate massive future deficits that everyone agrees are unsustainable. They are also rife with fraud and abuse.
And yet the current political debate and the several and incomplete versions of “reform” proposals do little to address these core problems. Proposals such as those that would create a new public insurance program, for example, would likely magnify them and create a new generation of problems that will be as difficult to fix as Medicare has proven to be.
Why does the current set of reforms fall short? One reason is that all changes must pass through the political process. For example, any effort at Medicare reform rapidly morphs into a struggle for influence between insurers and pharmaceutical companies, big-city academic health centers and hospitals in rural areas, specialists and primary care providers, federal and state governments, and on down the line. Sadly, innovators — and all too often patients — get lost in these power struggles. Any reform effort that fails to correct the acknowledged fiscal and organizational flaws of Medicare and Medicaid while extending the political gridlock that attends it to a broader segment of the health care system is doomed to failure.
Some have offered novel approaches to “payment reform,” but none of these can realistically claim to both increase quality and reduce costs, while being acceptable to Congress. One proposal would create a new executive branch commission to propose changes to Medicare benefits and price controls that Congress could only override with a supermajority vote. While such an experiment might have the potential to reduce political gridlock, it would centralize power in a manner that seems exceptionally risky for a field that accounts for one-sixth of our economy and affects the lives of hundreds of millions of people. I anticipate many new advances in diagnostics, therapeutics, and devices over the coming decades. Optimal development and application of these will flow from a decentralized and innovative health care market and will be suppressed by a system that relies on politics and an all-powerful commission.
Some have proposed that comprehensive reform must be achieved quickly, capitalizing on a sense of crisis. I see unacceptable risks to this approach. Instead of achieving a far-reaching and necessary solution for our economy and the nation’s health, the necessity of pleasing enough special interests to get a bill passed will exacerbate our long-term crisis of cost and access. Who can tell what deals within a thousand-page bill that few, apart from lobbyists, have read will influence the state of health care for decades to come?
Now that a vote on health care reform will not occur until at least the fall, we should seize this opportunity by stepping back, making the right diagnosis, and then applying therapies that address the underlying disease. Here are a few ideas, based on the diagnoses discussed above, that may work. As with any therapy, these should be introduced as pilot programs, to be extended only if data reveal the desired outcomes. While such an approach will not fulfill the wish to produce a dramatic cure through a single stroke of legislation, it may avoid the pitfalls of the latter approach and have a greater likelihood of reducing the number of uninsured while controlling costs and enhancing outcomes. I propose this without any relationship to the partisan politics of the day that substitutes slogans and misinformation on both sides for meaningful analysis.
First, make the tax shelter for health insurance, currently limited to employers, independent of employment. This single, and morally imperative, step would enable the uninsured to use tax-sheltered money to buy health insurance for themselves while permitting insured employees, who are currently limited to a few employer-selected health insurance choices, to become more central in decision making.
Second, identify and eliminate the many barriers to entry and innovation in the health care and insurance marketplace. Eliminating what are often hidden barriers to competition will encourage entrepreneurs to offer lower-cost ways of financing and delivering health care, approaches that will deliver greater health care value for the dollars spent.
Third, make a serious effort, despite the context of widespread political demagoguery, toward deeply reforming Medicare and Medicaid. As one of many possible examples, try giving some Medicare and Medicaid enrollees earned income credits so they can make cost-conscious decisions among competing health plans. The sicker and less affluent should receive larger transfers, so they can buy adequate coverage. Among other benefits, such an experiment could break the logjam in payment reform and reliance on fee for service and centralized price controls.
Reducing rather than increasing the role of politics in health care decisions, while providing assistance for those in need, these pilot therapies would have the salutary effect of placing patients and innovators in a more central role as we determine the future of health care in America. And we would then, at last, be able to align the treatment with the disease, a fundamental principle of responsible medicine.
Addendum. I coauthored an article on health care reform and its underlying issues in 1994, and although it was written fifteen years ago, some of the concepts within this article may be relevant today (1). In addition, a recent article in the Atlantic magazine addresses key issues underlying this discussion that I find quite compelling but could not address due to considerations of length (2).
In this article, the determinants of health care expenditure per capita in Spanish regions are analysed. The coexistence of several models concerning the degree of spending power decentralization and financing systems makes Spain a singular case and allows us to draw conclusions relevant for other countries decentralizing their health care systems. Analysing the Spanish case also serves to show a number of pitfalls affecting econometric estimation of the effects of income and demographic structure on health expenditure. Because the reliability of parameter estimates is a key issue in the literature on the determinants of health expenditure, these potential problems should be taken into account when estimating and interpreting results.
El Sistema Nacional de Salud (SNS) presenta una compleja situación de equilibrio, que aunque puede ser satisfactorio a corto plazo, plantea grandes problemas de sostenibilidad y gobernabilidad; el incierto balance del proceso de descentralización sanitaria en España señala claramente la senda de buscar nuevas alternativas organizativas para hacer efectivas las ventajas de la descentralización, a la vez que ser capaces de aprovechar las economías del sistema y conseguir la equidad pretendida. Se proponen cuatro líneas de actuación: redefinición del SNS en torno al aseguramiento público y derecho cívico igual para todos; replanteamiento del sistema de financiación y del papel del fondo de cohesión; redefinir el papel del gobierno central y el Ministerio de Sanidad, y crear un nuevo organismo, la Agencia del SNS con un Comisionado que de soporte organizativo e identidad al SNS como ámbito de acción cooperativa. The Spanish National Health System (SNHS) is currently in a complex equilibrium which, even if acceptable in the short term, faces major sustainability and governance challenges; the so far inconclusive outcome of the SNHS decentralization process clearly underlines the importance of seeking new alternatives to effectively bring about the real benefits of decentralization, while taking advantage of the system's economies of scale and achieving its equity objectives. To this end, four lines of action are proposed in this paper: first, redefine the SNHS based on universal public coverage, as a civic right and equal for all; second, reframe the financing system and the role of the Cohesion Fund; third, review the role of central government and its Ministry of Health, and fourth, create of a SNHS Agency headed by a Commissioner, for providing an organizational framework and identity for the SNHS, and serving as the cooperative body of the seventeen Autonomous Communities’ Health Services.
Open access
Global Health Care Issues
Health Systems, Economic Evaluations, Quality of Life
A major shift appears to be underway in Europe in the relationship between national, regional, and local control over health sector decision-making. Since World War II, a central thrust of health policy has been to decentralize key dimensions of decision-making authority to increasingly lower levels of government, as well as (in Social Health Insurance systems and recently in some tax-based systems) to private sector organizations.1 This strategy, to adapt Kondratiev's business-cycle framework,2 has been one of two overlapping ‘long waves’ that helped frame structural decisions in most Western European health systems. The second wave—market-influenced-entrepreneurialism—has run simultaneously with decentralization since the late 1980s. However, while this second, market-oriented wave has generated considerable controversy in some health policy circles, the concept of decentralization was readily accepted in many national policy contexts. As a result, over the second half of the 20th century, expanded decentralization of authority to regional, municipal and non-governmental control has become part of the ‘received wisdom’ about what good health policy should include. In the tax-funded health systems in Nordic countries, for example, most administrative and managerial responsibility as well as substantial political (policy) and fiscal decision-making control has been decentralized inside the public sector: from national to regional level (somatic hospitals in Norway in 1970; mental hospitals in Sweden in 1967), from regional to municipal level (elderly residential care in Sweden in 1992), and from national to municipal level (effective decision-making control over central hospitals in Finland in 1993). In the tax-funded health systems in Southern Europe, most administrative and managerial as well as many political (but not key fiscal) responsibilities were devolved from national to regional governments in Spain (to the 17 autonomous communities from 1981 to 2003), and in Italy (to 22 regional governments starting in the late 1980s). In social health insurance funded countries in continental Europe such as Germany and the Netherlands, most administrative and managerial as well as many fiscal (but not key political) decisions have long been delegated to private not-for-profit bodies (sickness funds and hospitals), under a form of ‘enforced self-regulation’ grounded in explicit national statutory responsibilities.3 In many cases, this particular form of decentralization has been in place since those systems’ inception. In the more state-based social insurance systems that have emerged since 1990 in many Central European countries, various forms of decentralization have been utilized. Reacting strongly to the prior highly centralized Semashko model, countries decentralized ownership of hospitals from national to regional (Hungary) and local (Estonia, Poland) governments. The Czech Republic even termed its decentralization of hospital ownership to municipal governments as ‘privatization’. In similar fashion, centralized funding structures of the Communist period were decentralized into regional social health insurance funds in countries such as Poland, the Czech Republic and Slovakia. The strategic role of decentralization was further strengthened by changes in overall governmental structures in Europe. During the 1980s and 1990s, national governments increasingly ceded areas of sovereign power upward to European Union bodies, while at the same time that they were losing responsibilities downward to increasingly assertive regions—a process captured by the popular 1990s discussion about a ‘Europe of Regions’. This overall reduction in the role of national governments served to reinforce the health sector experience that the era of centralized power at the national level in Europe was fast receding. In the first years of the 21st century, however, this conventional wisdom has started to come undone. Far from continuing to recede, the role of the state in the health sector has begun to strengthen measurably. Instead of reinforcing the continued decentralization of authority away from national governments, state institutions have reversed course and are seizing responsibility for substantive political and fiscal decision-making in European health care systems. It now appears that in the near-term future only administrative and managerial authority—e.g. day-to-day operating decisions—will remain decentralized to lower level and/or non-governmental organizations. These counter-indications can be observed in many of the health systems noted earlier. In the tax-funded system in Norway, the national government took over political and administrative/managerial responsibility for all hospitals in the entire country in January 2002, removing control from the 19 regional governments (counties) that had previously owned and operated the public hospitals and transferring the administrative role to five newly created regional bodies appointed from Oslo. The national government also set out new rules for how these regions were to manage their hospitals—as ‘public enterprises’. Fiscal responsibility for health care remained, as before, a national responsibility. In Denmark, the national government initiated a major re-structuring of the health sector in January 2006. In the new configuration, the number of regional governments was reduced from 14 to 5, and their powers were greatly reduced. Fiscal and most political responsibilities were centralized back to the national government, with certain prevention and chronic care issues being re-allocated to the municipalities (also consolidated, from 271 to 98). At the end of these changes, the new regions retained little more than administrative and managerial responsibility for hospitals. A similar pattern of regional consolidation and a strengthening of the state role appears to be underway in Sweden and Finland. In Sweden, a royal commission is expected to recommend that the number of regional level governments (which have responsibilities for hospital and also primary care) be reduced from the current 21 to between 6 and 8. Similarly, in Finland, the national government is expected to propose that the number of central hospital districts, currently 22, be reduced to 18, and also that the number of municipalities (responsible for primary, nursing home and home care services) be reduced from 450 to about 250. In the United Kingdom, similar recentralization can be seen in the transformation of England's Regional Health Authorities from line to support functions, as well as in current plans to reduce the number of Primary Care Trusts from 300 to 150. In Ireland, key operating responsibilities were recently shifted from regional health care boards to a health executive at central level and the regional boards were abolished. A parallel, if less aggressive, thrust toward more state control over both political and fiscal decisions can also be observed in several social health insurance funded countries. In the Netherlands, the national government in 2006 changed the health system's funding structure from a sliding 50% employee/50% employee paid model to a 100% individually paid fixed premium, supplemented by social assistance funds (e.g. taxes) for low income citizens. The Dutch government also, since the late 1990s, has been ratcheting up the percentage of total expenditures for which the private not-for-profit sickness funds are at risk, forcing funds to manage their money more efficiently. In Germany, the federal government in 2009 is scheduled to take on responsibility for pooling all social health insurance contributions and then allocating them to the sickness funds on a prospective, risk adjusted, capitation basis. While this funding model has been in place in the neighboring Netherlands for many years, in Germany it would represent a major move toward centralizing fiscal responsibilities away from the private not-for-profit sickness funds and into the hands of a national government body. In Central Europe, Poland, in 2003, pulled operating control over its social health insurance system away from 17 regional funds and back into the Ministry of Health. From the perspective of national health policymakers, this process of re-centralization appears to reflect a complex set of concerns. Structurally, there is substantial worry about the aging of their populations (e.g. more elderly), the rapid growth of expensive new clinical technologies, and the economic constraints on health sector funding generated by European regionalization as well as the globalization of markets. Administratively, there is evidence in countries like Finland and Norway (also concerns in Denmark) that local control over health sector decision-making has led to increased disparities in services provided and in outcomes to vulnerable populations—in short, that decentralization has heightened equity problems. Economically, there are worries that local finance bases are insufficient to fund expensive future care needs, and that local administrative arrangements are inefficient and duplicative. Politically—an important factor in Northern European tax-funded countries—there is a sense among national politicians that they are being blamed when the health system fails to meet the expectations of the citizenry, and that national policymakers need to have the necessary organizational levers to correct these problems. Technically, the introduction of electronic medical records and other computerized reporting systems has reduced the transaction costs of information and made it feasible to more closely monitor health system performance from a central level. While many of these dilemmas with decentralization were predicted earlier in theoretical assessments,4 one can see strong elements of their concrete manifestation in the current movement toward re-centralization. Moreover, since these causal factors are long-term in nature, their recent importance lends strength to the argument that re-centralization may indeed represent a long-term structural shift in national health strategies. Several important questions arise from these examples of re-centralizaton in both tax funded as well as social health insurance funded health systems. One is whether the observed changes represent more than just the normal ebb-and-flow of policy development in European health systems, and instead signal a fundamental shift in the overall pattern of these decisions. A related question is whether political and fiscal authority will continue to migrate from regional and municipal to national government, leaving mostly administrative and managerial forms of control at the lower levels. The underlying issue here concerns the mix of national and local authority that typically exists within most European health care systems, and whether the main bias in structuring that mix might be changing from one favouring decentralizing to local governments into one that favors centralizing authority back to national governments. Posed more provocatively, one might ask whether a new “long wave” of re-centralization has now begun, pointing toward a health policy future of stronger national governments and weaker regional, local, and delegated private (SHI) institutions. There are—as Kuhn's theory about the complexities of paradigm shift would predict5—several confounding factors in arriving at satisfactory answers to these questions. One issue concerns whether a new ‘long wave’ of re-centralization can co-exist comfortably—as decentralization did—with the parallel long-wave pattern of market-influenced entrepreneurial measures, particularly in tax-funded health systems. Will re-centralization and entrepreneurialism reinforce each other, as happened previously with decentralized local units? Second, there are several exceptions to this broad pattern of increasing re-centralization across European health systems. One clear exception is in countries with serious ethnic conflicts, for example Bosnia-Herzegovina and Macedonia in the Balkans, and also in Belgium. Recent history suggests that decentralization may be essential in these highly charged political environments, in that various forms of local control are typically linked to the survival of the state itself. Another conceptually messy question concerns the pattern of continued regional decentralization of health sector decisions in Southern European countries like Italy and Spain. Regional governments in these two countries have fiercely defended their recently gained authority in the health sector, and have forced their less convinced central governments (Spain in 2003, for example) to tread carefully in designing new national programs to monitor performance or set standards for quality and outcomes. Of course, Spain and Italy both have histories of earlier regional sovereignty. Moreover, both are geographically larger and have bigger populations than Nordic countries—although they are roughly equal in size to the United Kingdom and also Poland. There is, further, within both Italian and Spanish regions a tendency toward greater internal centralization inside the regions themselves. Despite these caveats, however, it appears that Italy and Spain are pursuing greater decentralization at the same point in time that Northern European countries are shifting away from decentralization in their health systems. This brief review of recent health sector patterns raises a series of questions that do not allow for easy answers. A further complicating factor is the apparent lack of fit between continued local control over services to the elderly (home care, social assistance, also nursing home care) and increasing central control over fiscal and policy decisions in the overall health sector, which implies that re-centralization may soon confront key structural limitations. The current distribution of health sector evidence does suggest, however, that many European health systems will continue to see a tightening of state controls, especially over fiscal and quality-related matters. In this clash between national and local governments, it would appear that, on balance, democratic control at the national level will strengthen, taking increased authority over political and fiscal decisions, while democratic control at the regional and municipal level will weaken, and be increasingly focused only on administrative and managerial decisions. Moreover, given the rapid melting of public–private boundaries within many European health systems, this greater state role will likely be combined with growing public as well as private sector entrepreneurialism, despite the appearance that greater reliance on market-oriented decisions contradicts tighter state control over health system behaviour. While the particular balance between increased state controls and increased entrepreneurial initiatives will vary from country to country, this new blend of two ‘long waves’, with increasing levels of state authority over key health sector decisions, will likely define the future policymaking framework for many European health systems in the near-term future. Earlier versions of this argument were presented at the Third International Health Policy Conference in Jerusalem (December 2006) and the Annual Meeting of the European Public Health Association in Helsinki (October 2007). This version has benefited from comments made by a number of colleagues at both meetings, and especially from Josep Figueras, David Chinitz and Charles Phelps. An earlier version of this article is included in the conference proceedings of the Jerusalem meeting.
Open access
Health Systems, Economic Evaluations, Quality of Life
Albert J. Jovell, Robert J. Blendon, María Dolors Navarro, Channtal Fleischfresser · 7 authors
BACKGROUND: Fifteen years ago, public opinion surveys in Spain showed substantial dissatisfaction with the health-care system. Since that time, health-care in Spain has undergone significant changes, including a decentralization of the system, an increase in spending and a change in the way the system is financed. OBJECTIVE: This study examines how Spanish citizens rate the performance of their health system today, both as compared with other sectors of society and as compared with earlier time periods. METHODS: Data are drawn from nationally representative telephone surveys of the non-institutionalized adult Spanish population (age 18 years and over). The study was carried out in two phases: October-November 2005 (n = 3,010) and January 2006 (n = 2,101). RESULTS: The majority of the Spanish population thinks the health system needs to be changed. The problems cited relate mostly to long wait times to get health-care. Nevertheless, over the last 15 years, the proportion of people who have very negative views about the health system has decreased by half. The majority believes that not enough money is spent on health-care, but few people would support an increase in taxes to provide additional funding. The survey finds the National Health System's institutions and health professionals to be more highly trusted than other institutions and professional groups in the country. CONCLUSIONS: Government policy-makers in Spain face a dilemma: the public wants more health spending to decrease wait times, but there is substantial resistance to increasing taxes as a means to finance improvements in the system's capacity.
Contracting is one of the tools increasingly being used to enhance the performance of health systems in both developed and developing countries; it takes different forms and cannot be limited to the mere purchase of services. Actors adopt contracting to formalize all kinds of relations established between them. A typology for this approach will demonstrate its diversity and provide a better understanding of the various issues raised by contracting. In recent years the way health systems are organized has changed significantly. To remedy the under-performance of their health systems, most countries have undertaken reforms that have resulted in major institutional overhaul, including decentralization of health and administrative services, autonomy for public service providers, separation of funding bodies and service providers, expansion of health financing options and the development of the profit or nonprofit private sector. These institutional reshuffles lead not only to multiplication and diversification of the actors involved, but also to greater separation of the service provision and administrative functions. Health systems are becoming more complex and can no longer operate in isolation. Actors are gradually realizing that they need to forge relations. The simplest way to do that is through dialogue, although some prefer a more formal commitment. Interaction between actors may take various forms and be on different scales. There are several types of contractual relations: some are based on the nature of the contract (public or private), others on the parties involved and yet others on the scope of the contract. Here they are classified into three categories according to the object of the contract: delegation of responsibility, act of purchase of services, or cooperation.
China's transition into a market economy has exerted some influence on the health sector in terms of a significant growth of facilities, but it has also produced a range of destabilizing social costs. \n \n \n \nThis thesis analyzes the relations between healthcare pricing and payment reforms and the different delivery aspects such as the exemption program for the poor, public health programs for tuberculosis control and the provision of hospital services. A health economics and systems conceptual framework is used for analyzing aspects of the health systems in terms of market failures and the institutional response from governments and regulators. \n \n \n \nIn study I, the exemption programs for hospitals where the poor are relieved of paying the price or user charges are analyzed. The study is a case study where patient records from nine hospitals were reviewed, together with interviews with key informants and community representatives. The study showed that the discount offered was limited, where only a minority of indigents received discounts and the hospitals lacked incentives for efficiently carrying out the programs. \n \n \n \nStudy II investigates the effect of the new urban health insurance system on hospital charges. The study uses two tracers, acute appendicitis and normal childbirth, at six hospitals from two cities with different insurance systems. The result showed a lower rate of increase in hospitals charges in the city implementing the urban health insurance reform. Regression analysis showed contracting mechanisms and length of stay to be the main determinants for hospital charges. \n \n \n \nStudy III analyzes the operation of TB control programs in a decentralized financial system. A case study was conducted in four counties with different economic developments in the Shandong province. Data was collected from a review of documents and interviews with patients and key informants. The study showed weak government support to the TB control program and less developed DOT (directly observed therapy) programs in the poorer counties. TB patients suffered heavy financial burdens. The decentralized financing system had negatively affected the provision of public health programs such as TB control programs. \n \n \n \nIn study IV, the impact of retail price control of drugs on hospital drug expenditures was examined. The study is a case study at two hospitals. Total drug expenditures were analyzed based on financial records and a tracer, cerebral infarction, was used for an in-depth examination of prices, volume, expenditures and rationality of drug use. Findings showed that after the implementation of the drug pricing policy, total drug expenditures increased as rapidly as before. Drug expenditure per patient for cerebral infarction showed indistinct results, indicating that the regulation was not effective. Utilization rather than price was more determinative for drug expenditures. \n \n \n \nStudy V investigates the development of revenues, costs and performance in the hospital sector. In a sample of 41 hospitals in two cities, the use of inputs, investments and productivity was estimated. The findings showed that hospitals had expanded their staff and invested in new medical equipment. The corresponding change of outputs in terms of outpatient and inpatient performance showed a slower increasing rate, resulting in a diminishing productivity rate over time. \n \n \n \nThe market-oriented health care system in China is faced with different 'market failures' problems such as limited access to health services for the poor and the inaccuracy in relying on market mechanisms for services characterized by positive externalities, such as the public health programs. Financial autonomy has given health providers the incentives to maximize revenues. Government interventions to contain costs and improve efficiency show that a sole reliance on the price mechanism is insufficient and must be combined with other tools set by regulators and insurers.
Decentralization of health services in Uganda, driven by the structural adjustment programme of the World Bank, was embraced by government as a means to change the health institutional structure and process delivery of health services in the country.Arising from the decentralization process, the transfer of power concerning functions from the top administrative hierarchy in health service provision to lower levels constitutes a major shift in management, philosophy, infrastructure development, communication as well as other functional roles by actors at various levels of health care.This study focused its investigation on ways and levels to which the process of decentralization of health service delivery has attained efficient and effective provision of health services.The study also examined the extent to which the shift of health service provision has influenced the role of local jurisdictions and communities.Challenges faced by local government leaders in planning and raising funds in response to decentralized health service delivery were examined.The study used a descriptive survey research design employing qualitative techniques, namely questionnaires, structured interviews, observation, and document analysis to establish the extent to which the decentralized approach to health service delivery has impacted on local governments and the vulnerable target groups such as the rural and urban poor, children, mothers, HIV/AIDS victims, orphans and refugees.Key respondents were government officials in health related management in the country at various levels.Health workers and beneficiaries of health services were interviewed to share their views and experiences of decentralized health care service provision.iii Using a conceptual framework of "Community as Client", the findings illustrate that while some local governments in the country have extended health units closer to some communities, the pursuit of a decentralized health service delivery system in Uganda over-assumed the benefits of decentralizing health care.The observations indicated that health care is not better organized; neither has decentralization provided greater involvement of local communities in mobilization and capacity building of community-based health workers.The acclaimed cost containment and reduction through duplication of services, reduction of inequities, integration of activities of different agencies and organizations involved in health care have not been achieved in concert with original expectations and assumptions of decentralization.These include: strengthened health policy and planning functions of the ministry of health, improved implementation of health programmes, greater community control and financing (ownership) and improved inter-sectoral coordination.From the findings, it would appear that the motivation for decentralizing health care was not intrinsically guided by how the decentralized health system can better serve the poor majorities in the country.The study concludes that the decentralization of health services in Uganda was not matched with commitment for provision of necessary health supplies, and delivery of health care services through a centrally coordinated national network of health facilities.The Ugandan Government in particular Ministry of Health and the government needs to evaluate the achievements and challenges faced by the health care system under decentralization within the broader perspective of health for all, as a means to establish appropriate refocusing of health care delivery for optimal benefit of the client communities.
One of the limitations of cross-country health expenditure analysis refers to the fact that the financing, the internal organization and political restraints of health care decision-making are country-specific and heterogeneous. Yet, a way through is to examine the influence of such effects in those countries that have undertaken decentralization processes. In such a setting, it is possible to examine potential expenditure spillovers across the geography of a country as well as the influence of the political ideology of regional incumbents and institutional factors on public health expenditure. This paper examines the determinants of public health expenditure within Spanish region-states (Autonomous Communities, ACs), most of them subject to similar financing structures although exhibiting significant heterogeneity as a result of the increasing decentralization, region-specific political factors along with different use of health care inputs, economic dimension and spatial interactions.
ABSTRACT - The Portuguese National Health Service (SNS), a universal, centralized and public owned health care system, exhibits an extraordinary record of equalization in the access to health care and health gains in the late thirty years. However, the most recent history of the Portuguese health reform is pervaded by the influence of decentralization and privatization. Decentralization has been present in the system design since the 1976 Constitution, at least in theory. Private ownership of health care suppliers and out-ofpocket expenditures, on the financing side, both have a long tradition of relevance in the NHS mix of services. The initial aim of this study was to demonstrate expected parallelism between health reforms and public administration reforms, where a common pattern of joint decentralization and privatization was observed in many countries. Observers would be tempted to consider these two movements as common signs of new public management (NPM) developments. They have common objectives, are established around the core concepts of gains in effectiveness, efficiency, equity and quality of public services, through improved accountability. However, in practice, in Portugal, each movement was developed in a totally separated way. Besides those rooted in the NPM theory, there are few visible signs of association between decentralization and privatization. Decentralization, in the Portuguese SNS, was never intended to be followed by a privatization movement; it was seen merely as a public administration tool. Private management of health services, as stated in the most recent SNS legislation, was never intended to have decentralization as a condition or as a consequence. Paradoxically, in the Portuguese context, it has led invariably to centralized control. While presented as separate instruments for a common purpose, the association between decentralization and privatization still lacks a convincing demonstration. Many common health care management stereotypes remain to be checked out if we want to look for eventual associations between these two organizational tools.
ABSTRACT - The Portuguese National Health Service (SNS), a universal, centralized and public owned health care system, exhibits an extraordinary record of equalization in the access to health care and health gains in the late thirty years. However, the most recent history of the Portuguese health reform is pervaded by the influence of decentralization and privatization. Decentralization has been present in the system design since the 1976 Constitution, at least in theory. Private ownership of health care suppliers and out-ofpocket expenditures, on the financing side, both have a long tradition of relevance in the NHS mix of services. The initial aim of this study was to demonstrate expected parallelism between health reforms and public administration reforms, where a common pattern of joint decentralization and privatization was observed in many countries. Observers would be tempted to consider these two movements as common signs of new public management (NPM) developments. They have common objectives, are established around the core concepts of gains in effectiveness, efficiency, equity and quality of public services, through improved accountability. However, in practice, in Portugal, each movement was developed in a totally separated way. Besides those rooted in the NPM theory, there are few visible signs of association between decentralization and privatization. Decentralization, in the Portuguese SNS, was never intended to be followed by a privatization movement; it was seen merely as a public administration tool. Private management of health services, as stated in the most recent SNS legislation, was never intended to have decentralization as a condition or as a consequence. Paradoxically, in the Portuguese context, it has led invariably to centralized control. While presented as separate instruments for a common purpose, the association between decentralization and privatization still lacks a convincing demonstration. Many common health care management stereotypes remain to be checked out if we want to look for eventual associations between these two organizational tools.