20 abr 1015 saltman eng

An Overview of Recent Reforms in Western European Health Systems : 

An Overview of Recent Reforms in Western European Health Systems Richard B. Saltman, Ph.D. Professor of Health Policy and Management Rollins School of Public Health Emory University Research Director and Head European Observatory on Health Care Systems Madrid Research Hub

Western Europe has over 15 years experience with market-influenced health system reform: 

Western Europe has over 15 years experience with market-influenced health system reform

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Netherlands Dekker Report (1987) Sweden Patient Choice initiatives (Stockholm County) (1988) United Kingdom Working for Patients (1989)

By 2004, Western Europe hasa wide variety of health reform “stories”: 

By 2004, Western Europe has a wide variety of health reform “stories”

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Central and Eastern Europe (CEE) and Former Soviet Republics (FSR) have an even wider variety of health reform experiences

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Many CEE/FSR stories follow key patterns seen in Western European health systems and health reforms

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However: Different historical/political/cultural context Different economic circumstances Focus here: Western European experience

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Three Parts: Part I: Broad Policy Observations Part II: Innovative Mechanisms Part III: The Cultural/Social Dimension

Part I: Broad Policy Observations: 

Part I: Broad Policy Observations Three general observations about recent health reform strategies in Western Europe

Observation #1:: 

Observation #1: Funding frameworks have become more tax-based since the late 1970s

Five countries shifted from Social Health Insurance-based (private not-for-profit)to Tax-funded (public):: 

Five countries shifted from Social Health Insurance-based (private not-for-profit) to Tax-funded (public): Italy 1978 Portugal 1978 Greece 1983 Spain 1986 Luxembourg 1992

No country in Western Europe shiftedfrom tax-funded to Social Health Insurance (None shifted to for-profit private insurance) : 

No country in Western Europe shifted from tax-funded to Social Health Insurance (None shifted to for-profit private insurance) Conversely:

Observation #2:: 

Observation #2: In tax-funded countries: Funding as well as management increasingly decentralized to elected regional bodies: UK (Scotland, Wales, N. Ireland) 1999 Spain 1988 – 2003 Italy 1998 (Sweden, Denmark, Finland) ----------------------- (Norway: recentralization of hospitals 2002)

Observation #3:: 

Observation #3: Micro-efficiency (institutional level) pursued predominantly on supply side rather than demand side of health systems

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From administration to management (NPM) Hospitals as public firms/trusts/foundations (Sweden, UK, Norway, Spain, Italy, Portugal) Primary care as purchasers (Sweden, Finland, UK) Patient choice of provider [Sweden, Denmark, Norway, UK (2003)] Verdict: ongoing/fairly successful Many tax-funded health systems pursued constrained competition on production/ supply side:

Several Social Health Insurance countries pursued constrained competition on funding/demand side:: 

Several Social Health Insurance countries pursued constrained competition on funding/demand side: Patient choice between sickness funds (Netherlands, Germany, Switzerland) Nominal premium (Netherlands) Selective contracting (proposed) (Germany, Netherlands) Verdict: Mostly stopped (Germany) Heavily compromised (Netherlands) Under serious scrutiny (Switzerland)

Summarizing:: 

Summarizing: Funding frameworks became more tax-based Funding/management decentralized to elected regional bodies (tax-funded countries) Micro-efficiency pursued mostly on supply/ production side of health system purchaser/provider split patient choice

Part II: Innovative Mechanisms: 

Part II: Innovative Mechanisms

Innovative Mechanisms:: 

Innovative Mechanisms: Sweden: Linking hospital/home care budgets in public sector (Adel Reform 1993) Constrained private contracting for public hospitals (Legislation 2004) Combined/Sliding scale outpatient co-payments (1997) National evaluation of regional performance (1992) Public sub-county PC purchasing boards (1990)

Innovative Mechanisms:: 

Innovative Mechanisms: Finland: Municipal health/social purchasing boards (late 1980s)

Innovative Mechanisms:: 

Innovative Mechanisms: United Kingdom: Public/private primary care purchasing (GP fund-holders 1991) (Primary Care Trusts 2001) Private financing (“PFI”) for public hospitals (1997)

Innovative Mechanisms:: 

Innovative Mechanisms: Spain: National Cohesion Act (“soft steering” to manage decentralization ) (2003) Analyses of regional performance statistics National/Regional Council

Innovative Mechanisms:: 

Innovative Mechanisms: Germany Primary care group experiments Praxisnetz Berlin (1996-2002) Nordrhein-Westfalen Pilot (2003- ) “No claim” bonuses One month premium rebate/year (1996-98; 2004- )

Innovative Mechanisms:: 

Innovative Mechanisms: Switzerland: Primary care group experiments 8% - 25% premium discount 7.6% of insured (December 2002) “No claim” bonuses 1993: CSS fund (1.2 million insured) 10% higher premium, but 15%/25%/35%/45% annual rebates 8,835 participants (December 2002)

Innovative Mechanisms:: 

Innovative Mechanisms: Netherlands: Primary care group experiments AGIS sick fund Diabetes pilot Preferred provider contracting No financial incentive to patients (voluntary) “No claim” bonuses March 2004 proposal to Parliament All sick fund participants Higher nominal premiums/low-expense rebates

Innovative Mechanisms:: 

Innovative Mechanisms: France: State purchase of private supplemental insurance for low-income (4.6 million persons, Dec. 2002) Médecins référants (Gatekeeper GPs) (1998) Voluntary/patient pays only 1/3 visit charge out-of-pocket September 2003: 10% GPs/17% insured

Part III: The Cultural/Social Dimension: 

Part III: The Cultural/Social Dimension

A number of interesting questions:: 

A number of interesting questions: Why were implemented/successful reforms predominantly on production (supply) side? Why were difficult/dropped reforms predominantly on funding (demand) side? Why was earlier movement on funding frameworks from SHI to tax-funded? Why opposite direction (officially) from CEE? Why no movement to for-profit private insurance (partial exception: Switzerland)?

Beyond pressures for radical reformBeyond siren call of market theoryBeyond “new institutionalist”assumptions:the predominance of cultural/social values: 

Beyond pressures for radical reform Beyond siren call of market theory Beyond “new institutionalist” assumptions: the predominance of cultural/social values

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A Policymaker’s View: “… Health policy is a political sector that, more than others, absorbs and reflects national developments, traditions, and cultures. Health systems are the results of decades of development and the rather individual response to a country’s social situation and profile.” Hans Stein, 2003 (Germany)

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An Anthropologist’s View: “Institutions may be changed, but this does not necessarily affect the societal norms, and when these remain unchanged, the persistent influence of a majority value system patiently smoothes the new institutions until their structure and functioning is again adapted to the societal norms.” G. Hofstede, 1980

Emphasis on cultural/social values in tax-funded systems:: 

Emphasis on cultural/social values in tax-funded systems: Equity in Services access quality Equity in Funding cross-subsidies not “actuarial fairness” State grants to poorer regions RAWP-style allocation systems Stability/security of institutional arrangements

Emphasis on cultural/social values in SHI systems:: 

Emphasis on cultural/social values in SHI systems: Self-regulation Corporatism Participation Pluralism Solidarity A “way of life”

Conclusion I:: 

Conclusion I: Thus far: health system reforms in Western Europe have broadly reflected dominant cultural/social values

Conclusion II:: 

Conclusion II: The future challenge to Western European policymakers: Harmonizing cultural/social imperatives with financial requirements in a period of rapid change: - demographically - economically - technologically

Conclusion III:: 

Conclusion III: A “Safe” Prediction: Most health system reform stories in Western Europe will have more chapters relatively soon