Master in Health Economics and Policy
Ethics and Health
(April 10-June 19, 2012)
Marc Le Menestrel
marc.lemenestrel@upf.edu
Raquel Gallego
raquel.gallego@uab.cat
Session 1: Why the ethics debate?
Managerialism in health care systems.
1. Managerialism and value change in the public sector.
2. Health care systems reforms since the 80s.
Essay: What are the main threads of the health care reforms carried out
over the turn of the century? What can we learn from them?
Required reading:
Docteur, E.; Oxley, H. 2003. Health-care systems: Lessons from the reform experience. Paris: OECD, pp. 7-50.
(http://www.oecd.org/dataoecd/5/53/22364122.pdf)
Optional reading:
Ferlie, E. et al. 1996. (eds.) The new public management in action. Oxford: Oxford University Press. Ch. 1, pp.129.
Lane, J.E. 2000. New Public Management, London: Routledge, pp.1-15
Le Grand, J.; Bartlett, W. 1993. (eds). Quasi-markets and social policy. London: Macmillan. Ch 2-4, pp. 13-92.
Paris, V., M. Devaux and L. Wei. 2010, “Health Systems Institutional Characteristics: A Survey of 29 OECD
Countries”, OECD Health Working Papers, No. 50, OECD Publishing.
(http://dx.doi.org/10.1787/5kmfxfq9qbnr-en)
Pollitt, C. 1993. Managerialism and the public services. Oxford: Blackwell. 2nd edition, pp.1-27.
1. Managerialism and value change
in the public sector.
1.1. Managerialism as an ideology
1.2. Dualities past/present: private sector
1.3. Dualities past/present: public sector
1.4. Exercise
1.5. Doctrinal components of NPM and performance
assumptions
1.1. Managerialism as an ideology (I)
• Ideology: set of believes and practices assuming that
(better?) management can effectively solve economic
and social problems:
– Route to social progress lies through the achievement of
continuing increases in economically defined productivity.
– Productivity increases come from the application of ever-more
sophisticated (information and organization) technologies.
– Application of technologies can only be achieved with a labor
force ‘disciplined in accordance with the productivity ideal’.
– ‘Management’ is the organizational function that plays the crucial
role in achieving such productivity. Qualities and professionalism
of managers are the key to business success.
– To perform this crucial role managers must be granted ‘room to
maneuvre’ (i.e. ‘right to manage’)… Apocalyptic role.
Source: (Pollitt 1990)
1.1. Managerialism as an ideology (II)
• ‘Classic’/private sector management functions:
– POSDCORB: Planning, Organizing, Staffing, Directing, Coordinating, Reporting, Budgeting (Gulick and Urwick, 1937)
• ‘Public’ management:
– Expenditure planning and financial management
– Procurement
– Civil service and labour relations
– Organization and methods
– Audit and evaluation
(Source: Barzelay 2001)
1.1. Managerialism as an ideology (III)
1. Set of values and ideas in relation to society:
– Society should have clear objectives, motivated
workers, no red-tape, freedom of transaction
– Best management practices are in the private sector,
not in the public sector
2. Identification of social groups:
– Better off: managers, business people
– Worse off: politicians, unions, professions, public
sector employees
1.1. Managerialism as an ideology (IV)
3. Justifies behaviours and attitudes:
– Favours autonomy, confidence, individualism,
competitition
– Downplays control, hierarchy, equality
1.2. Dualities past/present: Private sector
Dimensions
Traditional firm
New firm
Jobs
Simple
Multidimensional
Roles
Controlled
Empowered
Values
Protective
Productive
Manager
Supervisor
Coach
Structure
Hierarchies
Flat
Performance
Activities
Results
Aptitude
Training
Education
Source: Hammer and Champy (1993)
1.3. Dualities past/present: Public sector (I)
Traditional Public
Administration
Providers orientation
Monopolistic provision
Compulsion
Uniformity
Dependency culture
New Public Management
Users orientation
Pluralistic provision
Freedom of choice
Organizations form
diversity
Self-sufficiency culture
Soruce: Adapted from Ranson and Stewart (1994) and Metcalfe (1996)
1.2. Dualities past/present: Public sector (II)
Bureaucratic paradigm
Post-bureaucratic paradigm
Public interest
Efficiency
Administration
Control
Specification of functions, authority and
structures
Justification of costs
Imposition of responsibility
Outcome value for citizens
Quality and value
Production
Achieve norms acceptance
Identifying mission, services, clients and
impacts
Value of provision
Building accountability processes
Focus on human resources
Understanding and applying norms
Identifying and solving problems
Ongoing improvement of processes
Separating service and control
Building support for norms
Widen consumer choice
Facilitate collective action
Provide incentives
Measuring and analyzing results
Learning from evaluation
Complying with norms and procedures
Functioning of administrative systems
Source: Barzelay (1992)
Managerialism as an ideology:
Some references…
• Osborne and Gaebler (1992) Reinventing
Government
• Peters and Waterman (1993) In search of
Excellence
• Moore (1995) Creating public value.
Exercise:
Management models
• Are there any differences between private sector
and public sector management?
–
–
–
–
–
–
Values
Aims
Decision-making (-ers)
Evaluation criteria
Property rights
Responsibility/accountability rules
Management models:
Some authors…
• Metcalfe
• Ranson and Stewart
• Flynn
• Hughes
• Self
• Walsh
• Dunleavy
• Hood
2. Health care systems reforms
since the 80s.
2.1. Health care markets
2.2. Health system models
2.3. Health care reforms since the 80s
2.1. Health care markets (I)
• Health markets involve agency relations between:
Insurers
P/A
Purchasers
A/P
Providers
P/A
Professionals
Citizens
A/P
P/A
2.2. Health systems models (I)
• Institutional models of health systems
Reimbursement model: governmental grants to
mutualities (private insurance in Switzerland and
Netherlands)
Public contract model: National health insurance (Social
security contribution in France and Germany)
Integrated model: National health service (pre-90s in
the UK and New Zealand, and Spain)
Reimbursement model
Public contract model
Integrated model
2.3. Health care reforms since the 80s (I)
• Problems common to all health system models
– Inequity of access to services, of resource
distribution, and of health states/levels between
groups and regions (waiting lists…)
– Increase in health expenditure without an impact on
the population health state (pressures from both
demand and supply sides)
– Inefficiency: variability in medical activity and costs;
poor coordination between health care levels (primary
and specialized)
2.3. Health care reforms since the 80s (II)
• Problems common to all health system models
(cont’d):
– Citizens’ dissatisfaction with impersonality and
bureaucracy in service delivery
– Third-party payer (mal)functions:
• Insurance/coverage: assumption of health financial risk
• Access: to health services by the population
• Agency: intelligent buyer on behalf of its principal
2.3. Health care reforms since the 80s (III)
• “New public management”
– Purchaser/provider separation
– Disaggregation of hierarchically integrated
institutional structures into quasi-autonomous and
single function- organizations (regulation, financing,
purchasing, provision…)
– Managed competition on the basis of contracts
2.3. Health care reforms since the 80s (IV)
• Adequacy, equity and income protection
– Extensions to compulsory insurance systems (Spain,
Netherlands, Ireland)
• Macro-economic efficiency
• Micro-economic efficiency
• Convergence towards the public contract model
2.3. Health care reforms since the 80s (V)
• Macro-economic efficiency measures:
Cost containment and overall expenditure limits
– Demand side: cost-sharing through
• co-payment (fixed amount for a service)
• co-insurance (set proportion of a service cost)
• deductibles (fixed amount to be paid for a service
before any benefit payment is received);
• negotiation of fees for service and pharmaceutical
prices;
• publicly financed basic insurance
2.3. Health care reforms since the 80s (VI)
• Macro-economic efficiency measures (cont’d):
– Supply side:
• Limits to global activity volume
• Global budgets for physicians (Germany, Belgium)
• Global budgets for hospitals (Netherlands,
Belgium, France, Germany)
• Capitation payment for primary care providers
2.3. Health care reforms since the 80s (VII)
• Micro-economic efficiency measures: productivity
and efficiency in the system
– Switch from integrated to social insurance contract
model (former Eastern Germany)
– Managed competition between:
• Medical professionals (Germany, United Kingdom)
• Pharmaceutical products (Germany, Netherlands)
• Hospitals (Germany, United Kingdom,
Netherlands)
• Insurers or fundholders (United Kingdom and
Netherlands)
2.3. Health care reforms since the 80s (VIII)
• Convergence towards the public contract
model:
– Reimbursement model: more strict regulations and
contracts (France, Belgium)
– Integrated model: introduction of contracts and
disaggregation (United Kingdom)
– Competition between public purchasers/insurers
(United Kingdom, Netherlands)
– Wider consumer choice (Germany, Belgium and
Netherlands)
– Mix financing systems (budget limits and fee for
service)
– Selective and informed purchasing rather than
passive financing
Conclusions:
What relevance for ethics?
•
Definition of actor/function:
– Legal personality
– Ownership
– Regulation
•
Mecanisms of interrelation between actors/functions:
– Caracteristics of the contractual relation
– Regulation
•
Governance structure:
– Hierarchy
– Network
– Market
•
Dynamic context:
– Politics
– Economy
– Society