Health and Welfare Models in a Changing Europe/World Parallel Session 2

Transcription

1 Health and Welfare Models in a Changing Europe/World Parallel Session 2 2. December 2016, Rome, Italy Marcel Leppée

2 Health systems: all the institutions, people and actions whose primary purpose is to improve health. WHO, 2000 OBJECTIVES Improving people s health and well being Responding to people s expectations Providing protection against the costs of ill-health

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4 HEALTH SYSTEM HEALTH SERVICES Health Services are the set of institutions and programs that provide: Direct care to health and disease needs of individuals; and Public Health Services for the protection of collective health, (i.e. the health of communities).

5 Health Systems Reforms XX and XXI Centuries Up to the 1920s: Sanitary Campaigns : Social Security systems (Bismarck model) s: Welfare State systems (Beveridge model) s: Primary Health Care (Health for All Alma Ata) 1990s: Cost-containment and efficiency driven (International Financial Institutions) 2000 to date: Renewal of Primary Health Care People Centered Care Integrated Healthcare delivery Social Protection in Health Universal Access to Health and Universal Health Coverage (Universal Health)

6 There are about 200 countries on our planet each country devises its own set of arrangements for meeting the three basic goals of a health care system: keeping people healthy, treating the sick, and protecting families against financial ruin from medical bills.

7 But we don t have to study 200 different systems to get a picture of how other countries manage health care. For all the local variations, health care systems tend to follow general patterns. There are four basic systems.

8 The Beveridge Model Named after William Beveridge, the daring social reformer who designed Britain s National Health Service. Health care is provided and financed by the government through tax payments, just like the police force or the public library. Many, but not all, hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge.

9 Countries using the Beveridge Model or variations on it are: Great Britain most of Scandinavia Spain New Zealand Hong Kong still has its own Beveridge-style health care, because the populace simply refused to give it up when the Chinese took over that former British colony in Cuba represents the extreme application of the Beveridge approach; it is probably the world s purest example of total government control.

10 The Bismarck Model Named for the Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19 th century. This model uses an insurance system the insurers are called sickness funds usually financed jointly by employers and employees through payroll deduction. Bismarck-type health insurance plans have to cover everybody, and they don t make a profit. Doctors and hospitals tend to be private.

11 A multi-payer model (Germany has about 240 different funds ). Tight regulation gives government much of the cost-control clout that the single-payer Beveridge Model provides. The Bismarck model is found in: Germany France Belgium The Netherlands Japan Switzerland to a degree, in Latin America.

12 The National Health Insurance Model This system has elements of both Beveridge and Bismarck. It uses private-sector providers, but payment comes from a government-run insurance program that every citizen pays into. Since there s no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for-profit insurance. The single payer tends to have considerable market power to negotiate for lower prices National Health Insurance plans also control costs by limiting the medical services they will pay for, or by making patients wait to be treated.

13 The classic NHI system is found in: Canada Taiwan and South Korea (as newly industrialized countries have also adopted the NHI model)

14 The Out-of-Pocket Model Only the developed, industrialized countries perhaps 40 of the world s 200 countries have established health care systems. Most of the nations on the planet are too poor and too disorganized to provide any kind of mass medical care. The basic rule in such countries is that the rich get medical care; the poor stay sick or die. Hundreds of millions of people go their whole lives without ever seeing a doctor. They may have access, though, to a village healer using home-brewed remedies that may or not be effective against disease.

15 In the poor world, patients can sometimes scratch together enough money to pay a doctor bill; otherwise, they pay in potatoes or goat s milk or child care or whatever else they may have to give. If they have nothing, they don t get medical care. rural regions of Africa India China South America

16 Difference United States - all other Americans have elements of all of them in their fragmented national health care apparatus. The United States is unlike every other country It maintains so many separate systems for separate classes of people. All the other countries have settled on one model for everybody.

17 Healthcare models There are two main types of healthcare systems in Europe: 1. The tax-funded model (eg UK, Scandinavia) is a singlepayer, predominantly public, system with salary or capitation reimbursements, where patients have a choice of providers and specialist access is regulated through General Practitioners. 2. The social insurance model (eg Germany, Netherlands, France) has both multiple payers and owners of provider assets with fees being levied for services, where patients have a choice of insurers and direct access to specialists.

18 European healthcare systems are in urgent need of reform. Converging pressures of: 1. an ageing population, 2. the growing burden of chronic diseases, 3. shortages of healthcare workers and 4. increased demand for care are significant challenges for healthcare systems.

19 Health Services: What pushes the need to change? Changes in Demand Demographics Epidemiology People s Expectations Changes in Offer Knowledge and Technology Work Force Issues Financial pressure Social Changes Globalization Reforms of the State Sectorial Reforms Health Services Adapted form Mc Kee, M.; Healy, J. 2002

20 MODELS OF CARE A logical framework that defines what services will be provided to address the health needs, demands and expectations of the population. Bio-Medical Model of Care Social Model of Care People-Centered Model of Care

21 Bio-Medical Model of Care Focuses on the physical or biological aspects of diseases and illness. It is a medical model of care practised by doctors and/or health professional and is associated with the diagnosis, cure and treatment of disease.

22 Bio-Medical Model of Care Centered on acute episodic care, Supply driven and organized by levels that fragment care Hospital-based and dependent on costly technologies and specialist care, Provision of curative services through fragmented process of care, Lack of continuity, poor quality and safety, Inefficient referral systems, Generates of exclusion and dissatisfaction.

23 Social Model of Care This approach attempts to address the broader influences on health (social, cultural, environmental and economic factors) rather than disease and injury. It is a community approach to prevent diseases and illnesses. Focus is on policies, education and health promotion.

24 Social Determinants of Health inequalities in early years, levels of education, employment status, welfare and health systems, level of income, the places where men, women and children live, the norms and values of society, attitudes concerning gender and ethnicity all contribute to inequities in health. They are known as the social determinants of health.

25 People-Centered Model of Care 1. People centered 2. Integrated 3. Comprehensive 4. Continuous 5. Life Course approach

26 Integrated Care Integrated care is an approach for people and communities that seeks to identify and resolve gaps in care, or poor care co-ordination, that leads to adverse impacts on care experiences and care outcomes. Integrated care should not be solely regarded as a response to managing medical problems, the principles extend to the wider definition of promoting health and wellbeing. Integrated care is most effective when it is populationbased and takes into account the holistic needs of patients. Disease-based approaches ultimately lead to new silos of care. Nick Goodwin, 2014.

27 Comprehensive Care Services and interventions that span the spectrum of promotive, preventive, curative, rehabilitative, palliative and social care in both levels of services (First Level and Specialized care), and are coherent with person s life course; Integration of Public Health and healthcare delivery services.

28 Continuity of Care is the degree to which a series of discrete events in health care are experienced by persons as coherent and interconnected and addresses their health needs and preferences. (User perspective).

29 Continuity of Care Coordination mechanisms for: Sharing essential information for healthcare delivery Integrating care across levels and institutional boundaries Regulate access to different points of care in the network INSTRUMENTS: Evidence Base Medicine (clinical guidelines and protocols) Electronic health records Referral mechanisms Innovations in service delivery modalities (home care, daysurgery, specialty clinics in support of the First Level of Care, Telemedicine, etc.)

30 Health System Reform Criteria and Principles Common goal: the improvement of the health conditions of the populations. To promote equity in health conditions, access and coverage of services and financing of services; To improve quality of care from the technical standpoint and the user s perspective; To increase the efficiency of health financing, and allocation and management of resources; To ensure sustainability To promote social participation in planning, management, delivery and evaluation of health services.

31 Challenges for the next decades From professional orientation to client orientation From disease and intervention to health and prevention From patient dependancy and satisfaction to literacy, self management and co-creation From standardization to variation From quality systems and external control to performance improvement and zero-tolerance

32 Concluding remarks Some various issues

33 Technologies issues: Technology alone does not solve everything and not everything can be done by regulation. Technology may deliver efficiencies in healthcare, but not necessarily cost savings.

34 Data issues: Collecting data strengthens the evidence base for political choices in healthcare. Policymakers have the right to their opinion but not to their own version of scientific facts. Patients expect clinicians to have access to and use medical records to guide their treatment. However, when asked if they are prepared to share their personal health data, a significant proportion of patients refuse. This conundrum needs to be solved. Health data should be a public good, owned by the patients and health systems. The future of data should not be left to digital giants. Big data will help to drive change. Two new types of data genomic and patientgenerated will soon be more accurate and exceed the amount of data entered into medical records by doctors. Cognitive computing capacity can analyse this data and extract new insights. This is a future goldmine for health. Building trust into the system is critical for people to feel confortable sharing their health data. This requires authorisation mechanism, robust third party authentication and smart regulation.

35 Regulation issues: Not everything that is new is innovative or an improvement. Remove regulatory barriers when it is safe, and improves access for all. There is leadership and new thinking at EU level but implementation is blocked by cultural differences and regulatory barriers at national or local level. Regulators have a brief window of opportunity to manage the changes rather than just responding to external developments.

36 Individual/patient issues: The EU should do big, not small. Infrastructure needs to be put in place at EU level, but individual consumers will drive the revolution. Existing ehealth services show that patients trust digital service provision. However, healthcare systems are not designed for a business model that allows this trust to be exploited. The current working models are largely for those willing and able to pay for it outside the health system. Many public and insurance systems won't pay for virtual consultations, reinforcing the tradicional face-to-face model. Attention needs to be given to the human factor of changing behaviours and mentalities.

37 Innovative issues: Public procurement tends to focus on the short term issue of getting services for a cheaper price. A more holistic view of the overall healthcare system and its needs could prioritise innovation as a criterion for public tenders. There are pockets of change or innovation in different parts of Europe, but governments need to get better at identifying them and bringing them back home as pilot actions. Healthcare has to evolve from treating illness to maintaining health. In terms of information mamagement, this means starting to look forward using digital tools for insights and patient engagement.

38 KEY MESSAGE There is no single best practice for HSR (Health System Reform) in a changing Europe, but in order to contribute to improvements in population health, reforms should be congruent with citizens values; contain mechanisms to protect the poor; and strengthen the capacity of national and local stakeholders to plan, administrate, regulate, evaluate, and innovate.

39 Key Take Away Ideas There is a difference between integration of services and integrated care. Integrated service delivery is a key strategy for the attainment of Universal Access to Health and Universal Health Coverage (Universal Health) Integrated care and Integrated Health Services implementation tends to be more successful where there is a commitment to the values and principles of Primary Health Care

40 Four key conclusions emerge Social values become increasingly important as pressures on healthcare systems intensify. Political will to reflect social values while delivering effective healthcare is essential. Any renegotiation of the health social contract needs to be consistent with the demands of political accountability in a democratic society. There is unlikely to be a single solution to responding to challenges in delivering healthcare costs; an integrated approach that takes account of the broader context is essential.

41 LITERATURE Holder R. Health Services and Access Unit, Department of Health Systems and Services, July , Belize Friends of Europe., accessed: 14. November The Future of Healthcare in Europe. London s Global University, UCL European Institute and UCL Grand Challenges, London, UK, Pan American Health Organization World Health Organization

42 Thank you! 42