What Makes Health Care Systems work? An international Perspective

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1 What Makes Health Care Systems work? An international Perspective by Franz Knieps Managing Partner, Wiese Consult GmbH, Berlin, Germany (Former Director General for Health Care, Public Health Insurance, Long Term Care at the Federal Ministry of Health) November

2 Health Care Systems Definitions Organization of people, institutions and resources to deliver health care services to meet the health needs of target populations (Wikipedia) A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct health improving activities. A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. It includes, for example, a mother caring for a sick child at home; private providers; behaviour change programmes; vector control campaigns; health insurance organizations; occupational health and safety legislation. It includes inter sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well known determinant of better health. (World Health Organization) 2

3 Health Care Systems Goals Good Health Responsiveness to the expectations of the population Fair financial contribution (WHO) Cost Coverage Consistency Complexity Chronic illness (William Brody, Johns Hopkins University) Access for all High quality Sustainable financing (European Union) 3

4 Health Care Systems Evaluation Quality Efficiency Effectiveness Efficacy Acceptability Accountability Equity System integration But health policy, systems research, especially international comparisons must be handled with care. You must learn about before you can learn from. (Ted Marmor, Yale) 4

5 Health Care Systems Details to compare Coverage and access Benefit package / services and cost sharing Financing system Delivery system System governance and integration Quality assurance Public health strategies Management Human resources Innovations Evidence based medicine, care, decision making, health policy Information technology Patient empowerment and shared decision making Cost control 5

6 Health Care Systems Financial Resources General taxation Contributions to social health insurance Premiums to private health insurance Out of pocket payments esp. co payments Donations All types are compatible with an efficient health system. There is no relationship between financing and cost control. (National Bureau of Economic Research) 6

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10 Health Care Systems Strengths Full coverage for the whole population Wide range benefit package Freedom of choice between insurers and providers Easy access to medical, technical, pharmaceutical progress Strong (legal) position of patients and insured Good working conditions for health professionals 10

11 Health Care Systems Critical Issues Health status related to social status (income, education, origin) Variations of care and lack of integration Focus on acute care and dominant role of physicians esp. specialists Lack of public health strategies and prevention Under and oversupply Neglected aspects Primary care esp. in rural areas Access for (illegal) migrants Children and elderly people in poverty Mental diseases esp. dementia 11

12 Health Care Systems Future Challenges Demographic change Population Health professionals Medical, technical, pharmaceutical progress Globalization, migration, urbanization Ethics 12

13 Health Care Systems German Answers Incremental reform steps instead of a Big Bang Sophisticated cost containment approaches Focus on Competition (consumer`s choice) Primary care Integrated care, managed care, chronic care Drug regulation Looking for new financial sources Reforming the payment systems (p4p) Improving quality and efficiency Strengthening the users and patient empowerment Flexibilization of institutions and processes 13

14 Health Care Systems Further Steps Creating common markets for public and private insurers and providers Focus of a coherent public health strategy on Prevention and health promotion Evidence based health care Chronic care, long term care, rehabilitation Family medicine Outcome measurement and pay for performance Improving health education and coaching Patient empowerment and shared decision making Developing new models of integrated and managed care Improving e health and mobility Professionalization of management and staff 14

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