Prof Stiofán de Burca
Comparing Health Systems
Health System:
Encompasses all the activities whose primary
purpose is to promote, restore or maintain
health.
Comparability in Measuring Performance
 Ideology, System and Policy differences,
Welfare States (UK,NL,Fin,Swd,NZ,Can…)
 Centralist (Irl) and Devolved Systems
(Gm,Sp,Blg..)
 Values underpin stewardship, goals,
conceptual framework and potential impact
of Health System on health.
Comparability in Measuring Performance
 Data availability
 Sources and utilisation of information re
development, organisation and operation of
health systems and frameworks for assessing
performance.
 Intersectoral actions and influences e.g.
education, welfare, environment.
 GDP size, state of domestic economy,
population health needs and implications for
policy and practice
Health Expenditure OECD (30) 2004
Per Capita $
1. US...6102
2. Lux...5089
15.Irl.....2596
OECD...2550
16.UK...2546
29.Mex..662
30 T`key.580
Share% GDP
1.US...15.3
2.Swtz11.6
15Dmk 8.9
8.9
19 UK 8.3
26 Irl 7.1
29 Slvk5.9
30 Kor 5.6
Health Expenditure OECD (30) 2004
Public%Expd.
80+..Lx,Cz,Slv,UK,Swd,Dmk,
Nwy, Icl,Jp.
70+..Irl,Fr,Gmy,NZ,Fn,It,Hgy,
OECDTky,Pgl,Blg,Sp,Astr,Cn
.
60+..Pld,Astrl,Nl,
50+.Swtz,Grc,Kor.
40+..Mx,US.
Drugs Public%
1. Irl...89
2.Lux..84
.. 61
29.US..24
30.Mex.12
Comparability in Measuring Performance
 Key variables (WHO,2000)
 Environments (constitutional, political, legal,
economic, social and epidemiological)
 Overall level of health... DALE
e.g. WHO members.. 70yrs:24
60yrs:50%
>50yrs:32
 Distribution of health in population…
e.g. reduce inequalities to best attainable average
level of goodness
Comparability in Measuring Performance
 Organisation and management and
characteristics of service.
 Responsiveness to population expectations
and client/service orientation (level and
distribution)
 Distribution of Finance…level of funding
allocated to health system and fairness in
sharing.
 Reforms strategy and implementation plans.
Classifications:
 Main Funding Source.
(a) Bismarck Systems…Social Ins/Sickness
Funds…with well established financing (NL,
Gm, Blg.); Bm in transition..eg from
SEMASHKO.
(b) Beveridge Systems...General Public
Revenue…with well established financing (UK,
Swdn, NZ,Can.); Bv in transition.
(c) Mixed Group……….Bev+(Irl.), Bism+(Fr.),
Swz., Chn.
(d) Private………………US, Jpn.
No pure system!
Classifications (contd):
 Ins. Based
Austria
Belg
France
Grm
Lux
NL
Swz
In transition
GDR
Isr
Tky
Tax Based
Denmark
Fin
Icel.
Irl.
N`way
Swd
UK
In transition
GR
It
Pgl
Sp
Classifications (contd):
Main System of Delivery.
(a) Universal………….UK, Can.,Swdn NZ.,Fr
(b) Mixed…………….. +(Irl), US(ltd), Swz.
Chn.
(c)Private…………….. Jpn., US.
Classifications (contd):
 Patterns of Coverage
(a) Entire pop (compr compuls stat ins/Austr,Fr,Lx)
(priv and compuls /Blg,NL)
(vol m`ship/Swz)
(state ins/Grm)
(b) Majority (tax based/UK 90%,Fin 80%)
Exception (Irl 30%)
Resource Scarcity and Priority Setting
Availability:
 Ability of Welfare State to support universal
comprehensive cover.
 Cost containment, cost share.
 Cost effective resource allocation and
delivery interventions.
Resource Scarcity and Priority Setting
Priority setting:
 Role of values and ethical principles that underpin
choices in health care e.g.utilitarian and needs –
based.
 Epidemiological risks and burdens (QALY &
DALE).
 Levels…competing claims (polit)
area allocation choices (pol/mgl/clin)
treatments/inds (clins)
 Systems…Planned (det. priorities at macro-level)
 Competitive (ptns,clins in decn procs)
Resource Scarcity and Priority Setting
Rationing :
 Necessity, effectiveness, efficacy and ind
respon.(NL/ Dunning)
 Human dignity, need, solidarity, cost efficiency
and effect. (Swd/PPC)
 Epid. based, health needs assmt., key stakeholder
(UK)
 Exclusion (cap treatments/Oregon)
 Guideline (NZ/Core S. Cttee)
Equity as key principle to guide NL+Swd.
Effective Resource Allocation
Prospective Budgeting:
 Traditional…historical basis (Dmk,Pol)
adequate for allocation and cost containment
 Activity-adjusted…control –based soc ins
systems encouraged incr LoS (Fr,Gm)
 Case-mix –adjusted…activity and
severity(DRGs/Irl,It,Nwy)
Effective Resource Allocation
Efficient Delivery:
 Variations in Q,V&P..reflect diffs in
prevalence of disease, cult det prefs treatm
 Patterns of structural and fin incentives and
client uncertainty re most appropriate
treatment.
Effective Resource Allocation
1. Improvement Strategies:
 Nat Q devt policies (Blg,Dmk,Pol,Cz)
 Legal/contractual (Fr,NL,UK)
 Accreditation (Fr,NL,UK,Irl)
 Q indicators (PATH/WHO)
 Cochrane Collaboration
 Clinical performance
Effective Resource Allocation
2 a. Managerial:
 Decentralised provider autonomy and
responsiveness to purchasers and
patients.
2 b. Clinicians in management
 (UK,Nord) Techniques (
B`mark,BPR,Ptn Fcsd Care, QI,intl
control)
( H Info Sys)
Effective Resource Allocation
3. Restructuring hosps: (45-75% HC Res)
 Comparison of hosp data is difficult.
 Maj varn in no. beds per `000 and bulk of changes
1980/94
 Irl.: 9.5…………. 5.0
 UK: 8.1………….5.0
 Dmk: 8.1……… 5.0
 Gr : 6.2…………5.0
 N`wy: 16.5…… 3.1
 Swd: 15.1……… 6.4
 Fin:….15.5……...10.1
Size, configuration and performance:
 Distribution of specialist services?
 Scale and efficiency?
 Uncertainty of Outcomes and Volume
 Problem of level for analysis.
 EBMed and EBMgt?
Public Health Care
 Re-orient( Alma-Ata/WHO)..community and ind
involvement; redistribution away from hosps.,
intersectoral approach to policy.
 Integrative role of PHC.
 Primary Care: patient lists/geog defined, from
salary to capitation.
 Personal or family lists (Irl,Dmk,It,NL,UK)
 Gatekeeper to secondary Care
 Direct access to Splst Care(Gm), limited
(Sp,Pgl,It,Dmk)
Reforms: Largest role PHC... in countries
with control over part or all of other
delivery bgts.
Reforms
 Context
 Themes
 Challenges
REFORMS
Change in health care policies and in the
institutions through which they are
implemented…evolutionary or radical,
purposive, sustained and top-down.
Context
Norms and Values:
1. Solidarity (social/collective) or market –
oriented goals
2. Role of state in financing and delivery, or,
self-regulating associations, insurers and
providers.
3.Accountability(ethical,political,legal,professi
onal,financial) defines parameters of feasible
and sustainable health sector reform.
Context
Macro-economics:
1. GDP growth and % Health, Education,
Welfare
2. In Western Europe the public service
reduces capacity for private investment.
3. CEE falling revenues for Health Sector with
economic restructuring.
Context
Change Drivers:
1. Epidemiological e.g. ageing population.
2. Expectations, econ. cycles and political
requirements.
3. Technology Developments
4. National/ Instl. Strategies
Themes
1. Changing roles of State and market in Health
Care.
2. Decentralisation to lower levels of Public
Service.
3. Role, choice and empowerment of patients.
Reorganisation
As decentralisation, (deconcentration/admin,
devolution/polit and delegation), recentralisation
and privatisation of State`s role.
 Decentralisation (a central tenet of HS reform
due to widespread disillusionment with large
centralised b`cratic institutions and drawbacks
of poor efficacy, slow pace of change and
innovation, lack of responsiveness to
environmental changes affecting health care and
suspect to political manipulation)
Reorganisation
 Centralisation (H policy, strategic decisions
on H resources, regulations on public safety,
monitor, assess, analyse H of population and
H care provision; Irl?)
 Deconcentration (Poland
Provincial/Municipal power v Minstl., UK
Regions)
Reorganisation
 Devolution (Swedish Councils monopoly of
integrated responsibility/fin and service)
 Delegation (Italy Public Enterprises, Hungary self –
regulating system of H Insrs)
 Privatisation (Czech, Russ Fedn H Ins v
complicated and b`cratic, pressure for capital
returns affects social character of health service and
discriminates against sick and vulnerable; US
private insurers and avoidance of adverse risk
selection.)
Evolving role of patient
 Citizen participation: Charters (UK, Poland)
 Legal rights and Ombudsman (Finland)
 Legislation on med contracts/rights of
patients, contract law.
 Complaints System (UK, Irl.)
Challenges
 Health Status….measuring health and
disease( QALY,DALE) largely determined by
interaction of 4 linked factors,(genetic
susceptibility, behaviour and lifestyle, SES
and environmental conditions).
DALE











Oman
Malta
Italy
France
Spain
Japan
N`way
Sw`dn
UK
Irl
S. Afr
OVERALL
1
2
3
4
6
9
18
21
24
32
182
8
5
2
1
7
10
11
23
18
19
175
WH Report 2000
Basic Indicators (WH Report 2006)
 Total Pop., Annual Growth Rate, Dpdcy Ratio, Pop
% 60+ LE Birth, Fertility Rate, Prob
Dying/`000(5,15-60)
Life Expectancy at Birth:
 82yrs (Japn,San Marino)
 81yrs (Swz,Austrl)
 80yrs (Can,Andra,Fr,Isrl,Nz,N`wy)
 79yrs (UK,Cyp,Fin,Grm,Grc)
 78yrs (Irl,Blg,Cba,Dnk,Pgl,US)
 36/39 (Zimb,Swazl,S.Lne)
Service Quality
Adverse outcomes, small area variation studies
(US)
 40% clin decisions different for identical
complaints!
 20/30% clin care ineffective. Outcomes of
increased investment (7% to 10% GDP)
Choice of Provider
 GP (most tax-based and sick funds allow
choice eg Dmk.Gm; Fin assign.)
 Specialist self-refer eg NL,Gm
 Hospital (Swdn, Dmk. Restricted UK
contracts; Dutch attempt created problems
for social soliodarity; Isr only univl ins )
Equity
 UK/ Black Report,1980, demonstrated an
association between deprivation and ill health;
Can/Lalonde Report,1974.
 Health field concept ie product of lifestyle,
environment, human biology and Health Care
WHO, H for All Strat
 1984;Ottawa Charter H Prom
 1986 Action areas: h pub pol, supp envts, str comm.
action, dev psl skills and re-orient hs. Control over
h dets.
 Intersectoral action (WHO Healthy Cities Prog.)