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.
Humphreys & McLellan 1 advocate policies for more effective substance use disorder service systems that reward in-treatment outcomes, rather than long-term effects, and give patients purchasing powers in a treatment market. They write modestly that they do not know to what extent their (stimulating) conclusions about best strategies to improve treatment outcomes are relevant outside the United States and the United Kingdom. It is true that a demoralized staff with little professional competence and low status is not a problem that has been raised in Nordic discussions. Other matters mentioned have, however, also motivated centrally initiated reforms in our countries, such as a lack of medical competence and under-utilization of evidence within the systems. A concern for less resourced groups of substance abusers has also been expressed. Sweden has put much effort into implementing evidence-based treatment methods, and supported treatment of so-called heavy abusers. Integration between substance abuse treatment and (mental) health care are part of reforms or reform plans in Finland, Norway and Sweden 2-5. When these ideas have been accompanied by earmarked state funding they have influenced the local systems—but with largely unknown effects. Money matters most for reforms. There is a constant conflict between universalistic ideals and distribution of limited resources. In the Nordic countries, substance abuse treatment is financed mainly through taxes (with a mix of providers). The responsibility to provide various kinds of treatment in accordance with the needs of the population has been highly decentralized to the municipalities. At the local level, and particularly since the 1990s, with growing attempts to downsize the public sector, a primary interest in most reforms has been to decrease the costs of the services. Substance abuse treatment resources compete for (municipal) tax money with expenses for services, for instance, for the elderly or for daycare. Substance abuse treatment belongs to the social and health-care services that have the least support among the voters and politicians, and that will be the first to experience cuts when cuts are called for. Since the late 1980s, market models have been tried out in a variety of versions in the substance abuse treatment systems in all Nordic countries 2, 4, 6, 7. Market models change the systems swiftly, as they will directly allocate resources, and cost-efficiency within substance abuse treatment is assumed to increase through competition and consumer influence. Market models also seem to be a safe route to shrinkage of the public sector, which is accused of being inefficient. Consumer choice is finally ideologically in line with what is regarded today as normal for the empowered service consumers in the welfare systems. However, we lack evidence. Market models in good times can empower well-resourced substance use disorder clients with fewer chronic problems, but the application of market models in substance abuse treatment has been followed by many problems that could have been anticipated. The Swedish history of substance use disorder treatment shows that, in general, clients' possibilities to influence what treatment they received were greatest during the heyday of the universalistic welfare state, until the late 1980s. Those were the days with a centrally and locally planned good mix of services for all groups of problem users, with earmarked state subsidies to local treatment systems and with few financial restrictions. This was before the markets. From the consumer's viewpoint, in reality choice today is often limited. It is not only true that in most smaller communities there are no real alternatives, but in larger localities competition has also, in many places, implied a streamlining and uniformity of services. Sometimes there are local monopolies and sometimes a choice only between places with Minnesota model programmes or between doctors who prescribe more or less buprenorphine 8. Market models further create new bureaucracies, with the need to install financial control of purchasers and control of providers. Markets are not necessarily cost-efficient, and especially not from a population viewpoint, as the market will not meet all needs. The markets favour large groups, those that have more resources or solid public support and those that have better possibilities to reach recovery, however it is defined. The markets can have unintended, cost-increasing effects. Many opioid-using clients, if given the choice, will choose a doctor who subscribes more, rather than less, buprenorphine. It has also been pointed out that markets with competition can break up the continuity of care between different providers in a publicly planned system 2, 9. The authors call for realistic evaluations to accompany all new initiatives. It is easy to support this conclusion. It should also be applied to market models. We need more evaluations. We need to share more effectively the experiences we have. Service systems are dependent upon decisions about distribution. The market is not a good way to distribute services between clients with different levels of information, varying degrees of real choice and varying possibilities to correct their wrong choices. It cannot substitute the political decisions that will distribute services to all those who need them. There is no ‘quick fix’. We will have to accept that treatment systems change all the time, with changing problems and needs, that they should be evaluated constantly and publicly, with strong user involvement, and with open discussions about distributions of resources and social values. The market is not a solution. None.
William Newbrander, Chavanne L. Peercy, Megan Shepherd‐Banigan, Petra Vergeer
Fragile states need assessment of decentralized management capabilities, not just of the central level, to design capacity-building efforts focused on improving management. Improving the management capacity of health departments at the provincial or district level is just as critical as strengthening the central ministry in fragile states if a health system that effectively addresses the real health needs of the population is to be formed. This paper describes a management capacity assessment tool developed for use in fragile states. It uses a framework that describes six critical management areas: oversight and coordination; human resources; resource management; health financing; community involvement; and health information management. These core areas of health system management are assessed with regard to capacity in three core management functions: the capacity to plan, to implement, and to monitor and evaluate. The tool was applied to assess the management capacity of six counties in Liberia. The results helped differentiate the level of capacity of the different counties and clarify the actions required to strengthen the health system in the periphery. The assessment also allowed the prioritizing of county health offices with regard to the level of capacity building required to improve management. The tool also identified successes that can inform the design of future health programs in other county health offices. The tool can be applied to other challenging country situations to assess management capacity, which will help focus technical assistance to the health sector in fragile states.
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.
Much of current research on issues of equity in low- and middle-income countries focuses on uncovering and describing the extent of inequities in health status and health service provision. In terms of policy responses to inequity, there is a growing body of work on resource reallocation strategies. However, little published work exists on the challenges of implementing new policies intended to improve equity in health status or health service delivery. While the appropriateness of the technical content of policies clearly influences whether or not they promote equity, policy analysis theory suggests that it is important to consider how the processes of policy development and implementation influence policy achievements. Drawing on actor analysis and implementation theory, we seek to understand some of the dynamics surrounding the proposed implementation of one set of South African staff allocation strategies responding to broader equity-oriented policy mandates. These proposals were developed by a team of researchers and mid-level managers in 2003 and called for the reallocation of staff between better- and lesser-resourced districts in the Cape Town Metropolitan region to reduce broader resource allocation inequities. This was felt necessary because up to 70% of public health expenditure was on staff, and new financing for health care was unavailable. We focus on the views and reactions of the two sets of implementing actors most directly influenced by the proposed staff reallocation strategies: district health managers and clinic nurses. One strength of this analysis is that it gives voice to the experience of the district level--the key but much neglected implementation arena in a decentralized health system. The paper's findings unpack differences in these actors' positions on the proposed strategies, and explore the factors influencing their positions. Ultimately, we show how a lack of trust in the relationships between mid-level managers and nurse service providers influenced the potential to implement a specific set of equity-oriented strategies.
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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The main aim of this report is to present a picture of the current organization of nephrology in Spain. The Spanish health system offers almost universal coverage, a wide variety of services and a high-quality network of hospitals and primary care centers. Spain has a specialized health care training system that is highly developed, highly regulated, with the capacity to provide high-quality training in 54 different specialties. Nephrology is basically a hospital-based specialty. There are no private dialysis patients in Spain. Hemodialysis centers are 40% public, 15% private and 45% run by companies. The National Health System covers 95% of the population, and there is no cost to patients for treatment of renal disease (dialysis and transplant). We observed a clear decrease of nephrology in residents' election rankings, with position 29 out of 47 specialties in 2007. Some of the reasons for this are the complexity of the subject, no clear information at the university, reduction of professional posts and a very good public service with minimal private practice. In Spain, a model of organization for transplantation was adopted based on a decentralized transplant coordinating network. For cadaveric donors, it compares favorably with rates in other Western countries. Living donor transplantation is very low in Spain--just 10% of total renal transplantation activity. New programs due to financial constraints need to include reduced dialysis costs, greater cost-effectiveness of prescriptions, better handling of ethical issues related to the need for using a clinical score of chronic kidney disease patients to make decisions about conservative or renal replacement therapy and an action plan for improvement of organ donation and transplantation. Recovery of skills (acute kidney injury, biopsies, vascular access, etc.), research and advances in autonomous activities (imaging, surgical and medical vascular training, etc.) are some of the future educational paths needed in nephrology. Adequate decisions in the context of economic restrictions need to be discussed for the sustainability of nephrological care.
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
Along with resource generation, financing, and health service delivery, stewardship is a key health system function. However, very little empirical analysis has been carried out on it. This paper aims to fill this gap in the literature by assessing the Ministry of Health's (MoHs) role as a steward of the Spanish National Health System (NHS) after the 2001 decentralization reform of health care management to the Autonomous Communities. We use the following stewardship framework with six sub-functions for the analysis, looking at the MoH's ability to: (1) formulate strategic policy framework; 2) ensure a fit between policy objectives and organizational structure and culture; (3) ensure tools for implementation; (4) build coalitions and partnerships; (5) generate intelligence, and (6) ensure accountability. We describe the stewardship function, identify existing challenges and issues in the Spanish case, and reflect upon methodological aspects of this exercise. We use reports, documents, articles, and official statistics to complete the analysis. Overall, we find the MoH to give an average performance in its role as the steward of the health system. The MoH has progressed particularly well in generating intelligence as well as formulating a strategic policy framework over recent years. However, it lacks the appropriate authority to efficiently coordinate the health system and to ensure that the Autonomous Communities implement policies that are in-line with overall NHS objectives.
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.
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; 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. The Ukrainian health system has preserved the fundamental features of the Soviet Semashko system against a background of other changes, which are developed on market economic principles. The transition from centralized financing to its extreme decentralization is the main difference in the health system in comparison with the classic Soviet model. Health facilities are now functionally subordinate to the Ministry of Health, but managerially and financially answerable to the regional and local self-government, which has constrained the implementation of health policy and fragmented health financing. Health care expenditure in Ukraine is low by regional standards and has not increased significantly as a proportion of gross domestic product (GDP) since the mid 1990s; expenditure cannot match the constitutional guarantees of access to unlimited care. Although prepaid schemes such as sickness funds are growing in importance, out-of-pocket payments account for 37.4% of total health expenditure. The core challenges for Ukrainian health care therefore remain the ineffective protection of the population from the risk of catastrophic health care costs and the structural inefficiency of the health system, which is caused by the inefficient system of health care financing. Health system weaknesses are highlighted by increasing rates of avoidable mortality. Recent political impasse has complicated health system reforms and policy-makers face significant challenges in overcoming popular distrust and fatigue in the face of necessary but as yet unimplemented reforms.
According to a recent survey, a majority of U.S. physicians support health care reform that includes a new national public health insurance plan, which would compete with private plans.1 Polls have shown that a substantial majority of Americans support the public option as well.Yet the idea has occasioned considerable controversy on Capitol Hill. Senate Finance Committee chairman Max Baucus (D-MT) recently unveiled his draft bill (the chairman's “mark”), which contains no competing public plan. Instead, it substitutes the largely untested idea of providing federal loans and start-up funds to encourage the creation of decentralized, member-run health care “cooperatives.” Another . . .
Why do the states seem to be pursuing different types of policy innovation in their health reform? Why so some seem to follow a "solidarity principle," while others seem guided by a commitment to "actuarial fairness"? Our analysis highlights the reciprocal influence of stakeholder mobilization and public policy over time. We find that early policy choices about how to achieve cost containment led the states down different paths of reform. In the 1970s and 1980s, states that featured oligopolistic or near-monopolistic markets for private insurance (usually dominated by Blue Cross) and strong urban-academic hospitals tended to adopt regulatory strategies for cost containment that led to broader forms of pooling and financing the costs of health risks--which subsequently positioned them to pursue major, solidaristic reform on favorable terms. On the other hand, states with competitive markets for private insurance and weak, decentralized hospitals tended to adopt market-based strategies for cost containment that led to the hypersegmentation of risk and the uneven financing of costs--thereby encouraging the proliferation of incremental policies that reinforce the principle of actuarial fairness. We illustrate our analysis with a brief comparison of Massachusetts and California, and we conclude with some thoughts on what our findings imply for the federal role in catalyzing health reform.
Healthcare Policy and Management
Health Systems, Economic Evaluations, Quality of Life
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 essay a conceptual and theoretical scheme for decentralized integrated health care systems of the northern European kind is developed. With small changes it is also applicable to other countries, e.g. Italy, Spain, and Portugal. Three ideas tie together the scheme: modified fiscal federalism, principalagent thinking and the analysis of discrete structural alternatives from new institutional economics. As a special case it encompasses the ideas of planned markets and public competition developed by von Otter and Saltman. The scheme can be used to analyse driving forces behind reforms and prediction of effects. To illustrate the thinking the recent Norwegian reform is put into context, not only geographically but also theoretically. The geographical context is that of Scandinavia and there is a summary of reforms in the Scandinavian countries over the past 20-30 years. The essay thus serves the double purpose of presenting and evaluating the Norwegian reform in a Scandinavian context and to take part in the neglected discipline of developing a theory of health care reform. The Norwegian January 2002 reform is described in some detail. It is a reversal of the Scandinavian model of decentralization and a move towards more centralism. The hospital system was transferred to the state that established five regions with independent (non-political) boards and each region has a number of daughters (hospitals) that have great autonomy with their own boards and are outside the legal restrictions of the public sector. Basically the idea is to mimic the corporate structure of large private companies. The reform is evaluated based on principal-agent thinking and the analysis of discrete structural alternatives. Overall there is no a priori reason to expect large improvements in efficiency – but on the other hand neither should one expect things to get worse. Many effects depend, however, crucially, on (a) the financing system that will be put in place late 2002 or early 2003, and (b) whether or not the political and management culture change as a result of the reform. In the concluding sections possible implications for Denmark and Sweden are discussed.
Health sector reforms emerged as a major focus in the 1990s covering a wide range of structural and institutional changes. The components of a fundamental health sector reform includes: decentralization of power and resources; improving function of national health ministries; improving the performance of civil service (and managers); broadening health financing mechanism; introducing managed competition; guaranteeing access, redressing equity and pro-poor orientation; as well as broadening ownership and impact. Nigeria’s overall health system performance was ranked 187th among the 191 Member States by the WHO in 2000. The issue of financing and user fees has implications for reproductive health services uptake.
Where maternal services are rendered free there was an increase in service uptake where the quality of the services that are being provided are guaranteed. Local authorities or communities should be allowed to set their priorities based on their peculiar needs and problems of their locality, but such should not go against the main objective of the health reform. The approach of “basket funding” should be continued to ensure quality monitoring and evaluation of the health system in general and assuring the quality of health related data.
Key words: Health sector reforms, Reproductive health, Health financing mechanism, Nigeria
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