health sector reforms professor dr jw björkman institute of social studies & leiden university...
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Health Sector Reforms
Professor dr JW BjörkmanInstitute of Social Studies & Leiden University
The Netherlands
National School of Public HealthRio de Janeiro, Brazil
11 March 2009
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Overview of LectureI. Introductory definitions and issues
II. Approaches and generations of reform
III. Historical context and policy goals
IV. Capacity constraints and corrections
V. Models of funding and contracting
VI. Markets and public-private partnerships
VII. Types and strategies of health reforms
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Comparative Health Reforms
Reform = modify current arrangements Re-form seeks to change ‘form’ Target-issues in the health sector
1) access to health services
2) cost of health services
3) quality of health services
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Overview of Major Approaches
1) Institution Building – 1950s, 1960s
2) Institutional Strengthening – 1960s, 1970s
3) Development Administration – ’60s, ’70s
4) Human Resource Management – 1980s
5) Capacity Development – 1980s, 1990s
6) Millennium Development Goals – 2000s
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Generations of Reforms1) First– cut public expenditures and revive
the public sector
2) Second– improve efficiency & effectiveness of public administration
3) Third– improve service delivery through sector-wide approaches
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Repetoire of Policy Instruments
Establishment of autonomous organizations
Introduction of user-fees (pay for service)
Contracting out of service delivery Enablement and regulation of the
private sector
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Basic Goals in Health Policy
I. Universal access to health servicesII. Equity in sharing financial burdensIII. Good quality health careIV. Efficiency and cost controlV. Satisfaction of patientsVI. Autonomy of professionals
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Financing Health Care
General taxation
Health insurance
Out-of-pocket expenditures
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Historical Antecedents 1883 Germany’s mandatory social
health insurance for workers & their families (employment-based scheme of premiums)
1948 Britain’s national health service for entire population (population-based scheme paid out of general taxation)
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21st Century ‘Hybrids’
Employment-based arrangements for certain categories of workers are combined with population-wide and tax-based universal schemes.
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Retrenchment in 1970sOil crises and economic stagnationHigh unemployment, declining state
revenue, rising public expendituresDemographic shiftsIdeologies about the role of the statePolicy alternatives of competition and
market choice
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Recognition of Private Sector
Extensive private sector for health care in (almost) all countries
Primarily out-of-pocket paymentsLargely un-regulated and dominated
by medical professionals‘Public-Private Partnerships’ due to
declining government budgets
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Stage of Raising RevenuesReforms stimulated by economic recessionDeclining government revenues & budgetsPressure for reform emanate from central
ministries of finance & planningImposition of user-feesDwindling capacity of citizens to payTransaction costs
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Capacity Constraints (i)
Limited implementation of policies Time needed for proper assessment ‘The smaller the capacity, the greater the
ambition’ and vice-versa Staff features (numbers, skills, motivation) Organizational culture Patronage and favoritism
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Capacity Constraints (ii) Management information systems Incentive structures Lack of feedback Poor coordination Limited extent of the private sector
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Pressures for Policy Change Proliferation of cross-national studies Faulty assumption that policy as stated in
law is the same as policy implemented ‘Spending-Services’ cliché Reform = shifts in decision-making power
over allocation of resources and risks Shifts = intergovernmental, inter-personal
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Empirical Experience of HSR
Countries implement reforms within (a) their own institutional legacies, (b) varying speeds of change, and (c) with different timings
Describe any health system in terms of a country-specific mix of funding, contracting & modes of delivery
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Five Main Sources of Funding
1) General taxation
2) Public and private insurance
3) Direct payments by patients
4) Voluntary contributions
5) External aid from donors
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Three Basic Contracting Models
1) Integrated model – funding and ownership under same (public or private) agency
2) Contracting model – governments or third-party payers negotiate long-term contracts with health care providers
3) Reimbursement model – patient pays the provider, then seeks reimbursement from his/her insurance agency
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Other Contextual Elements
Country-specific mixes: Formal and informal care Traditional and modern medicine Medical and related social
services
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Health Care Reform: Bottom-line
Combinations of core elements – funding, contracting (including payment modes) and ownership – determine the allocation of financial risks and decision-making power among the main players in the health care sector.
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Explanatory Variables External and internal pressures for change Structural features of social policy-making Institutional legacies and history Popular support and/or opposition Top-down versus bottom-up reforms Degree of ‘ambition’ – overly elaborate =
plans remain on the ‘drawing board’
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Types of Health Reform (i) Structural Adjustment in disguise
(primarily cost-cutting) Market-oriented reforms
*Assumption: markets create efficiencyBut profits from unnecessary
careBut transaction costs
*Assumption: perfect information & choice
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Types of Health Reform (ii) Public health and public financing
(the ‘Cinderella’ of all options for reform) Note: there is nothing inherently wrong with
market-based reforms, provided they:
*work for greater efficiency and equity
*receive no government subsidies
*comply with regulations
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Types of Health Reform (iii)
‘Idealist model’ is flawed – a ‘perfect market’ (where demand, expressed as purchasing power, determines supply and utilization of health care services) only works if those who need care are also those with the most resources for buying the care they need … whereas, in reality, the opposite is true!
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Strategies of Reform (i)
1) Deep structural changes to ensure minimum care for all citizens
2) Beware ‘pretended’ reforms
3) People always pay – but who is to pay more and who is to pay less?
4) Centrality of the ‘central’ level
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Strategies of Reform (ii)5) Replace regressive fee-for-service with
prepayment schemes
6) Progressive taxes are the best revenue for public health and insurance
7) Rationalize resources by reallocating personnel and mobilizing for outreach
8) Participatory dialog for empowerment
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Strategies of Reform (iii)9) ‘Political will’ = choice and commitment
10) Health systems must help people get well when they are sick
11) Health systems must keep people healthy and stop them for becoming sick
12) Health systems must advance medical intervention and social transformation
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Observations (i)The role of governance in social policy and
development (Lavis & Sullivan 1999):
‘Healthcare systems play a significant role in why we get well when we are sick;
social environments play a significant role in why we are healthy or why we become sick in the first place’.
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Observations (ii)
Landmark aspirations*1947 United Nations Covenant on Social,
Economic and Cultural Rights*1978 Alma Ata Declaration of ‘Health for
All by the Year 2000’*1981 World Health Assembly strategy of
‘HFA & Primary Health Care’*2000 Millenium Development Goals
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Recent Trends in Reforms
public/private partnershipsstate ‘failure’ and market ‘failure’shift in emphasis from ‘poverty causes
ill-health’ to ‘ill-health causes poverty’ – and therefore health care provides opportunity for poverty alleviation as well as social development
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Conclusions about Reforms
Greater socio-economic equity is vital to tackle the challenge of health
Human right to health requires political commitment at all levels
Health inequalities are rooted in socio-economic structures
Action is needed in all social policies
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Health Sector Reforms
Obrigado!
Thank you for your attention!