Leadership and Governance Managing and Researching Health Care Systems Reinhard Busse, Prof. Dr. med. MPH FFPH FG Management im Gesundheitswesen, Technische Universität Berlin (WHO Collaborating Centre for Health Systems Research and Management) & European Observatory on Health Systems and Policies 23 November 2017 Leadership and governance / Care delivery 1
Outline of the course- Week 1 Topic Date Lecturer Introduction and Outline of the course 20.11.2017 15-17 Uhr Introduction and frameworks 21.11.2017 09-12 Uhr Financing I: Raising Resources Seminar on health system relevant databases and information for term paper Financing II: Pooling and re-allocation Financing III: Purchasing and payment systems Leadership and Governance + Care Delivery Wilm Quentin and Daniel Opoku Reinhard Busse 13.30-17 Uhr Wilm Quentin 22.11.2017 10-12 Uhr (H8173/74) Anne Spranger 13.30-17 Uhr Reinhard Busse 23.11.2017 09-12 Uhr Medical products 24.11.2017 9-10.30 Uhr Introduction to group exercise Wilm Quentin 13.30-17 Uhr Reinhard Busse Reinhard Busse 10.30-12 Uhr Anne Spranger Workforce 13.30-17 Uhr Claudia Maier 2
Outline of the course - Week 2 Topic Date Lecturer Preliminary Summary of building blocks Presentation by GIZ on health system related German development cooperation Access and Coverage 27.11.2017 09-10.30 Uhr Quality and Safety 28.11.2017 09-12 Uhr Financial and social risk protection Improved Health 29.11.2017 13.30-17 Uhr Efficiency and Responsiveness 30.11.2017 09-12 Uhr Summary of Health System Performance Assessment Group Presentations and Wrap-up 01.12.2017 09-12 Uhr 23 November 2017 Reinhard Busse 10.30-12 Uhr Ursula Bürger, Fachplanerin Kompetenz-Center Gesundheit und Soziale Sicherung, GIZ 13.30-17 Uhr Reinhard Busse Reinhard Busse 13.30-17 Uhr Wilm Quentin Wilm Quentin Reinhard Busse 13.30-17 Uhr Reinhard Busse Reinhard Busse or Wilm Quentin 3
WHO building blocks 27 Nov 21 Nov 30 Nov/1 Dec 23 Nov 24 Nov 22 Nov (seminar) 24 Nov 21 to 23 Nov Week 8 27 Nov 28 Nov 29 Nov 30 Nov 28 Nov 30 Nov 23 Nov WHO 2007 23 November 2017 Leadership and governance / Care delivery 4
Overview Definitions, components and development stewardship governance Underlying values, sub-functions/ principles and goals of governance Hospital governance/ regulation of hospitals 23 November 2017 Leadership and governance / Care delivery 5
The WHO Health system framework (WHR 2000) Stewardship is one of the four main health systems functions and is argueably the most important one. 23 November 2017 Leadership and governance / Care delivery 6
Stewardship and regulation Rowing less, steering more clear division of compentencies with role of state = stewardship: Health policy formulation defining the vision and direction for the health system Intelligence assessing performance and sharing information Regulation setting fair rules of the game with a level playing field (including possibly promotion of entrepreneurial activity!)... but not providing care! 23 November 2017 Leadership and governance / Care delivery 7
Financing I: Raising resources/ funding Population Coverage: Who? What? How much? Functions Financing II: Resource pooling & allocation Collector of Third-party Payer resources Financing III: Purchasing/ contracting/ paying providers Steward/ Regulator Policy formulation, Regulation Intelligence & Regulation Access to services Provision of services 23 November 2017 Leadership and governance / Care delivery Providers 8
WHO 2007 building blocks - The concept of stewardship did not grasp the complexity of health systems, association with strong leadership alone, e.g. steer the ship of state. - In 2007, changed to leadership and governance, with several subcategories: ensuring that strategic policy framework exist and are combined with effective oversight, coalition building, regulation and attention to system-design and accountability. Am Steuer, Kladderadatsch, vol. 32, No. 27 (June 15, 1879), p. 108. WHO 2007 23 November 2017 Leadership and governance / Care delivery 9
(Multi-level) governance Governance describes the process through which state and non-state actors interact to design and implement policies within a given set of formal and informal rules through which authority in a country is exercised. World Bank, 2017 Underlying assumption: actors of the health system should not act in a random way, but need to be steered towards pre-defined goals, based on values and principles A) Actors being governed Public sector, private sector, NGOs as health service provider B) Levels of governance Global level, European level, national level, sub-national, regional level or community level C) Areas (sectors) to be governed Pharmaceutical market, planning of human resources, pooling and spending of health expenditures D) Values and principles Transparency, anti-corruption, effectiveness, accountability, rule of law, ethics, inclusiveness 23 November 2017 Leadership and governance / Care delivery 10
Classifying dimensions of governance / principles / goals 23 November 2017 Leadership and governance / Care delivery 11
Components, functions and tools of governance: 4 x C Components (Sub-) functions Tools / strategies control Accountability (Performance-based) contracts, Capacity to sanction performance of individuals and organizations, external audits (financial, clinical, quality) coordination collaboration communication 23 November 2017 Formulating policy and strategies Regulation Organizational adequacy and system design Generating information/ intelligence Participation and consensus Partnerships Transparency National health plans, medical guidelines, priority setting of goals Rules, procedures, decrees; self-regulation by statutory bodies (e.g. professional associations) Monitoring and evaluation plan, Annual operational budgets, training Health technology assessment, audits, reports Patient reported outcome measures Open meetings, sector-wide approaches Health in all policies, consultation in health legislation Inter-ministerial committees, integrated budgets, information systems, common workforce training and qualification Releasing performance indicators, satisfaction surveys, watchdog committees Source: own compilation based on Barbazza and Tello 2014. Leadership and governance / Care delivery 12
Strategies of good governance, sorted according to attributes (= [sub-]functions or principles): the TAPIC framework Transparency Accountability Participation Integrity Policy Capacity - Watchdog committees/ inspectorates - Reporting requirements - Performance measurement - Freedom of information provisions - Public information efforts - Standards & code of conduct - Conflict of interest policies - Competitive bidding - Contracts - Financial mechanisms - Choice mechanisms - Regulation stategies - Organizational separation - Client surveys - Stakeholder forums - Advisory committees - Consultation - Representation (appointed or elected) - Legal remedies - Partnerships - Internal audit - Budget - Financial audit - Legislative mandate - Clear organization al roles and purposes - Personnel policies - Intelligence on performance - Intelligence on processes - Research and analysis capacity - Staff recruitment and retention Source: based on Greer et al. 2016 23 November 2017 Leadership and governance / Care delivery 13
In theory, Good governance is easy - Successful reforms are not just about best practice or copying efforts of another country - Power asymmetries can undermine policy effectiveness - Data availability to measure success of a policy - A policy can be limited because of a lack of financial means, short time period, lack of commitment, World Development Report 2017. Governance and the law 23 November 2017 Leadership and governance / Care delivery 14
But there are traps and governance failures - Health systems are found exceptionally prone to corruption and informal payment - This persists also with European countries Problems for accessibility, leading to inequities in health outcomes and sustainability of health expenditures World Development Report 2017. Governance and the law 23 November 2017 Leadership and governance / Care delivery 15
Measurement of governance is not straightforward Examples: outcome-based indicators Human Resources: Health worker absenteeism in public health facilities. Source: Greer et al 2016. Health Financing: Proportion of government funds which reach district-level facilities. Health Service Delivery: Proportion of informal payments within the public health care system. Pharmaceutical Regulation: Proportion of pharmaceutical sales that consist of counterfeit drugs. 23 November 2017 Leadership and governance / Care delivery 16
Hospital governance (regulation of hospitals) 23 November 2017 Leadership and governance / Care delivery 17
Type 1 hospital In an entrepreneur s ideal world, one could set up a hospital, determine how to run it and be responsible for all losses and profit. The right to establish a hospital would include the freedom to choose a location, to determine the size and to decide on the range of technology and services offered. One could also decide whether services to deliver on an in- or out-patient basis, set price levels and refuse to accept certain patients. Also, one had the right to decide on staffing numbers and qualification mix, the working conditions of the employees and their salaries. Lastly, there would be no restrictions on business relationships with suppliers and other hospitals, including the right for mergers and horizontal and vertical takeovers. 18 23 November 2017 Leadership and governance / Care delivery
Type 2 hospital In the other end of the spectrum, the national government (or a subordinated public body such as a Health Authority) establishes hospitals where and at what size deemed necessary according to a public plan. The planning authorities determine the technology installed and the range of services offered. Services are delivered free to all citizens at the point of service, hence no prices need to be set. Staffing and working conditions are decided by the public authorities and standard public salaries apply. As the hospitals are part of the public health services infrastructure, they have no independent relationships with other actors and no room for mergers or takeovers. 23 November 2017 Leadership and governance / Care delivery 19
Two types of non-regulation Private + hospital Public hospital + Both hospitals are not regulated: (1) There are intentionally no regulations to restrict the market behaviour of the hospital owners and/ or managers. (2) The hospital is subject to public sector commandand-control. In practice, most hospitals in many countries fall somewhere between the two extremes and require more regulation than these two. 23 November 2017 Leadership and governance / Care delivery 20
Autonomy Core public bureaucracy Few decision rights Private organization Full autonomy Market exposure None At full risk for performance Residual Public purse Organization claimant Accountability Hierarchical direct control Regulation and contracting Social functions Unfunded mandate Explicitly funded mandate 23 November 2017 Leadership and governance / Care delivery 21
Core public sector Budgetary Broader public sector Autonomous Privatized Corporatized Markets/ private sector From A Conceptual Framework for the Organizational Reform of Hospitals (A. Harding/ A. Preker, Worldbank) 23 November 2017 Leadership and governance / Care delivery 22
What are the objectives of hospital regulation? To enable hospital care: establishment and availability of hospitals, capacity and technology To promote and protect the population s health To specify and reward hospital services: access, types, payment, quality To get value-for-money/ not waste public resources To protect hospital employees To steer the business behaviour of hospitals 23 November 2017 Leadership and governance / Care delivery 23
Enabling hospital care Planning of capacities (by area, specialty): ex-ante (= before hospitals are built) or ex-post (= contracts for existing hospitals) Combining planning with money for investments Certificate of need for high technology 23 November 2017 Leadership and governance / Care delivery 24
Protect population s health Require accreditation, internal quality management, participation in external QA programmes, possibly with public disclosure of results (e.g. ranking lists) 23 November 2017 Leadership and governance / Care delivery 25
Specifying and rewarding hospital services Access: disallow patient selection, mandate nonscheduled admissions, require physician staffing around the clock, allow patient choice Types of services: There may be a case to restrict certain ambulatory services if they can be delivered more efficiently outside hospitals. Payment: uniformity of payment units (eg. DRGs) crucial for transparency, uniform prices less so Quality: minimum volume thresholds, inclusion of quality into payment 23 November 2017 Leadership and governance / Care delivery 26
Get value-for-money Require Health Technology Assessment for all (new) technologies Include technologies meeting pre-defined threshold or being prioritised into publicly financed benefit basket (provision public or private) Disallow technologies with harm > benefit even in private sector Regulate payment scheme with efficiency (among other objectives) in mind 23 November 2017 Leadership and governance / Care delivery 27
Protecting hospital employees (with relevant EU regulation in place) equal treatment, opportunities and pay for men and women (76/207/EEC and 75/117/EEC) right to part-time work (97/81/EC; 98/23/EC) safeguarding of employees rights in the event of transfers of undertaking, businesses or parts of businesses (77/187/EEC; 98/50/EC) working times (93/104/EC) 23 November 2017 Leadership and governance / Care delivery 28
Steering the business behaviour of hospitals Restrict (horizontal) mergers and acquisitions of other hospitals Restrict (vertical) mergers, acquiring and operating other healthcare institutions Mandate minimum financial reserves Restrict advertisements 23 November 2017 Leadership and governance / Care delivery 29
Conclusion Governance is about how things are done and how to achieve goals in a complex societal interaction. There are several problems to governance: as too little, too much or the wrong kind, but also short-sightedness, inefficiencies and unintended consequences. Governance is shaped by contextual factors, e.g. austerity after 2008 economic crisis Health system governance is a complex process, and the variation of governance performance and quality is likely to contribute to health inequalities across the world 23 November 2017 Leadership and governance / Care delivery 30
Einführung in das Management im Gesundheitswesen Care delivery Managing and Researching Health Care Systems Reinhard Busse, Prof. Dr. med. MPH FFPH FG Management im Gesundheitswesen, Technische Universität Berlin (WHO Collaborating Centre for Health Systems Research and Management) & European Observatory on Health Systems and Policies 23 November 2017 Leadership and governance / Care delivery 31
Agenda How do we define health service delivery and who provides health services? - International classifications Primary care: gate-keeping, choice, patient pathways and trends Inpatient care & standard measures 23 November 2017 Leadership and governance / Care delivery 32
The WHO Health system framework (WHR 2000) Service provision (WHO, 2000) is the organizational setting in which inputs and production processes are structured in order to deliver personal and nonpersonal health services. 23 November 2017 Leadership and governance / Care delivery 33
Who delivers which health services? International classifications of functions and providers 23 November 2017 Leadership and governance / Care delivery 34
Functions Collector of resources Steward/ Regulator Third-party Payer Purchasing/ contracting/ paying providers Population Access to services Provision of services Providers Generating resources 23 November 2017 Leadership and governance / Care delivery 35
Possible actors Collector of resources Third-party Payer Steward/ Regulator Population Providers GPs, specialists, dentists Ambulatory/ inpatient providers Public/ private hospitals... 23 November 2017 Leadership and governance / Care delivery 36
System of Health Accounts (SHA) large differences how health care provision is organized between countries international applicable classification is necessary and helpful Accounting framework is organized around three basic questions: What kinds of health care goods and services are consumed? Which health care providers deliver these goods and services? Which financing scheme pays for these goods and services? SHA undertakes a comprehensive classification of health care functions and health care providers 23 November 2017 Leadership and governance / Care delivery 37
SHA classification of health care functions The functional classification in the health accounting framework focuses on the grouping of health care goods and services by purpose A function relates to the purpose of health care consumption Classification of health care functions Curative care (general, specialised) Rehabilitative care Long-term care Ancillary services Medical goods Preventive care Governance and health system and financing administration Other health care services not elsewhere classified Mode of provision categories Inpatient care Day care Outpatient care Home-based care 23 November 2017 Leadership and governance / Care delivery 38
23 November 2017 Leadership and governance / Care delivery 39
SHA classification of health care providers traces health care expenditure by provider category: What is the organisational structure of the provision of health care within a country? Primary providers (HP.1-6) HP.1 Hospitals HP.2 Residential long-term care facilities HP.3 Ambulatory care providers HP.4 Ancillary services providers HP.5 Retailers and other providers of medical goods HP.6 Preventive care providers Secondary providers (HP.7-8.2) HP.7 Providers of health system administration and financing HP.8 Rest of the economy HP.8.1 Households as home health care providers HP.8.2 All other industries as secondary health care providers Health care providers encompass organisations & actors that deliver health care goods and services as their primary activity, and those for which health care provision is only one among other activities. 23 November 2017 Leadership and governance / Care delivery 40
23 November 2017 Leadership and governance / Care delivery 41
23 November 2017 Leadership and governance / Care delivery 42 Secondary activity
Inpatient vs. outpatient care Ambulatory/Outpatient Health services provided to patients who are not confined to an institutional bed as inpatients during time services are rendered: General medical care Diagnostic services Minor surgery, rehabilitation First aid, 24-hour availability Obstretic care, perinatal care Home visits, ambulance services and patient transport Palliative care Preventive services Health promotion services Inpatient Health service for a patient who is formally admitted (or hospitalised ) to an institution for treatment and/or care and stays for a minimum of one night in the hospital or other institution providing in-patient care (nursing homes, residential care facilities) >> includes accommodation provided in combination with medical treatment when the latter is the predominant activity. Primary and secondary care can overlap WHO OECD 23 November 2017 Leadership and governance / Care delivery 43
Difference in organisation of health providers Portugal Finland UK Sweden Spain Italy Greece Ireland Netherlands Slovenia Belgium Germany France Austria Switzerland inpatient outpatient inpatient outpatient inpatient GP GP GP GP GP GP GP GP GP GP GP GP Outpatient care SP GP GP SP SP GP SP GP 23 November 2017 Leadership and governance / Care delivery 44
Let s see how this looks in practice Public health centres (Terveysasemat) in Finland run by each municipality, first referral point for patients health centres can have several units and inpatient wards specialist care is provided in hospitals, but also health centres GPs work also in private practices outside health centre The Netherlands almost all specialists are hospital-based general hospitals have inpatient & outpatient departments GPs: 33% work in group practices (3-7 GPs), 39% work in two-person practices, 28% work in single-handed practice France outpatient care is provided by self-employed doctors (both generalists &specialists) in their own private practices outpatient nursing care is provided by self-employed nurses acute medical, surgical & obstetric care is provided by public & private hospitals, with different areas of specialization 23 November 2017 Leadership and governance / Care delivery 45
Typically we distinguish between 3 levels of care Primary care usually the first point of contact for patients within health care system provides a link to more specialized care usually based at the local level (provided in community-settings) includes general medical care for common conditions and injuries, health promotion and disease prevention activities accounts for 90% of all health activities Secondary care specialized ambulatory medical services and typical hospital services (outpatient & inpatient services), second contact with health system Tertiary care medical and related services of high complexity, usually of high cost and provided at university/ tertiary/referral hospitals Services attributed to each level and type of care vary significantly across countries. 23 November 2017 Leadership and governance / Care delivery 46
Primary care: gate keeping, choice, patient pathways and trends 23 November 2017 Leadership and governance / Care delivery 47
What is primary care (PC)? Primary care is first-contact, accessible, continued, comprehensive and coordinated care: first-contact care is accessible at the time of need; ongoing care focuses on the long-term health of a person rather than the short duration of the disease; comprehensive care is a range of services appropriate to the common problems in the respective population and coordination is the role by which primary care acts to coordinate other specialists that the patient may need. Who delivers primary care? General Practicioners (GPs), gynaecologists, pediatricians, ophthalmologists, dentists, and other physicians as well as nurses, pharmacists, physiotherapists, midwives etc. GPs are often the main primary care actors Soruce: www.euro.who.int/en/health-topics/health-systems/primary-health-care/main-terminology 23 November 2017 Leadership and governance / Care delivery 48
Primary care: Gate-keeping A gate-keeper is a practitioner who is responsible for overseeing and co-ordinating the health needs of a patient, as well as providing care themselves. The gatekeeper authorises referral of the patient to a specialist or hospital. Two objectives of a gate-keeping system: 1. limit the growth in health care costs by controlling the use of specialist and/or hospital services and reducing unnecessary interventions 2. ensure coordination and continuity of care by placing GPs at the centre of all care provided to patients 23 November 2017 Leadership and governance / Care delivery 49
Levels of gate-keeping 1) No gate-keeping: patients can freely access secondary care without referral and can use specialists as first contact points 2) Minimal gate-keeping: GPs act as referring doctors to specialized doctors and/or financial incentives may encourage patients to obtain referrals. 3) Gate-keeping with exceptions: GPs act as gatekeepers but patients can access certain specialists, e.g. gynaecologists, ophthalmologists, paediatricians, psychiatrists, without referral from a GP. 4) Complete gate-keeping: patients always need a referral from a GP in order to access secondary care services. 23 November 2017 Leadership and governance / Care delivery 51
Comprehensive assessment of primary care strength in Europe Primary Health Care Activity Monitor for Europe 2009-2010, Kringos et al. Outcome measures covered: Three dimensions of primary care structure: (1) primary care governance (2) economic conditions of primary care (3) primary care workforce development Four dimensions of primary care service-delivery process: (1) accessibility, (2) comprehensiveness, (3) continuity, (4) coordination of primary care. Operationalisation by 77 indicators for which data were collected in 31 countries Data sources included national and international literature, governmental publications, statistical databases, and experts consultations. 23 November 2017 Leadership and governance / Care delivery 52
Countries with strong, medium and weak primary care systems 23 November 2017 Leadership and governance / Care delivery 53 Source: Kringos et al (2012)
Choice of primary care providers In almost all European countries, patients are allowed to choose their primary care physician. User choice and competition have been increasingly introduced with reforms of privatization and stronger reliance on market mechanisms since 1970s There are different forms of choice: 1. Choice is limited to geographical area or period of time 2. Choice is limited to contracted providers (constitutes limitation only if there is a considerable number of non-contracted providers) 3. Unlimited choice 23 November 2017 Leadership and governance / Care delivery 54
Primary care: trend of convergence in Europe Most countries have aimed to strengthen primary/ambulatory care Western Europe: from individual towards group practices/health centres Eastern Europe: from health centres/polyclinics towards group practices/individual practice Trend in some countries of task delegation to nurses (Netherlands, Slovenia, Estonia, Sweden) Western Europe Individual HC/ Group Hospital Eastern Europe 23 November 2017 Leadership and governance / Care delivery 58
Moving away from inpatient/secondary care Western European countries reorganized hospital sector mostly trying to find new solutions and settings for service delivery (e.g. increase in day care activity) and by shifting treatments to the ambulatory sector outside hospitals. Western Europe Individual HC/ Group Hospital Eastern Europe 23 November 2017 Leadership and governance / Care delivery 63
Primary vs. inpatient/secondary care: trends Eastern European countries reorganized their public health systems with specialized hospitals and underdeveloped primary care system by: reducing the size of the hospital sector decentralizing health care provision strengthening primary care and expanding private providers Western Europe Individual HC/ Group Hospital Eastern Europe 23 November 2017 Leadership and governance / Care delivery 66
Key indicators for health care provision Input: physical resources (capital stock, infrastructure, medical equipment etc.) Operating indicators: hospital admissions/ discharges (in absolute numbers and per 1000 population) average length of stay (ALOS) mix of beds day cases bed occupancy rate medical procedures performed in hospitals 23 November 2017 Leadership and governance / Care delivery Source: OECD (2016) Health at a Glance 68
Conclusions categorization and distinction between health care levels (primary/secondary/tertiary) and care settings (inpatient/outpatient) is country-specific many countries aimed to strenghten PC more choice (but not necessarily unlimited) in primary care PC physicians play a stronger role as coordinators and gate-keepers in countries with traditionally weak gate-keeping secondary ambulatory care has become more important with increasing day care activity (diagnostic evaluation, surgeries, rehabilitation etc.) providing pre-admission and post-discharge care to patients as shorter length of stay in hospitals requires optimal preparation and follow-up 23 November 2017 Leadership and governance / Care delivery 73