Lecture 1: Introduction to Comparative Health Systems12/12/2012 1:29:

Finance minister gives the minister of health funds, decides how much What impacts health: Education o Secondary edu for women is very important Impacts fertility, prenatal health, childs health

Where does the health system fit into production of health? Proximate: health system, health behavior, psychosocial factors o Having a good doctor to take care of you when you have malaria Intermediate: education occupation, income, food, environment, working, conditions Structural: socioeconomics and political context

Have same good in 2 different places--you can buy more in one because the labor costs are lower in one Life expectancy vs health spending graph Graph shown is not looking at quality of life o Gets longer as you get older bc you pass bottlenecks

2: 1.further adjust it by purchasing power we can get 4:1 Non-health expectations: short wait time treat person w dignity participation privacy clear communication

Veteran heathcare in US similar to UK system Medicare payer model which is similar to Canada Goverance is key Service delivery what is it? Do you have to see a primary care doctor before you can see a specialist? o 80% conditions can be managed with primary care Watchful waitinga lot of stuff is self-resolving

Health workforce who are the doctors, PAs, and nurses? What are they paid? Information medical records, information collected about birth, deaths o o o Medical products, vaccines, technologies Financing Human resources

Fundamental mismatch btw health spending and health disparity - africa and south asiappl dying from preventable diseases lack the spending

luxury good 3 sources of money for heath spending 1) government Govt takes an increasingly bigger role when public spending increases 2) private 3) external external matters for low income counties

Out of pocket vs Premiums Out of pocket paid at the time of care Premiums paying before you get sick

Inefficient to make out of pocket main way we pay for health services you could lose everythingcould easily become bankrupt under purchase no pooling something that is important in reducing costs for public o no benefits in cross subsidizing

Lecture 2: Health care systems in high income countries (11/15) 12/12/2012 1:29:00 PM
Health financing indicators helps us understand the health system What does these numbers tell you? total expenditures on health General govt expenditure on health as % of total government expenditure total expenditues on health as % of GDP the size of the health care industry? o Tells us how big of a deal is healthcare in our economy o Usefull because it tells us if we are spending too much on health care? France and Ethiopia both spend about 6% GDP on health care Are the two comparable? NO! Output of the GDP is drastically different Govt expenditures on health as % of total expenditure on health govts investment in health care? Per capita expenditure on health What doctors earn? How many CT scaners we can afford? Whether country can accord to pay for kidney transplants? o o All the investment in country & divides it by the amount of people This govt has invested this much per person

The out of pocket spending as a % of all spending The burden of health care payments on the average family? o Out of pocket literally, what you pay out of your pocket Ideally we want insurance as a player in healthcare market

Wealthy countries History of health systems development Organized health systems did not really begin until 19th century Hospitals in 19th century, not a place you wanted to end up o o Last refuge werent there for cures, where you went to die They were a social safety net

1883, Germany enacted law to require workers to contribute a piece of their salary to a general pool to pay for health funds o countries of northern Europe began this idea of health insurance

1911, free care is mandatory

Classic health systems Bismarck o Social security predominates (employers and workers contribute to health funds) Beveridge o Extremely simple, general tax based fund collection o UK, Canada Germans = classic example

Semashko (hardly exists today) Tax funded, little or no private sector, universal coverage, free services centralized planning Cuba (somewhat today), formerly Soviet Union

Mixed (majority of health systems today) o Combination of tax-based, social insurance, out-of-pocket funding for health care US

Unregulated o o o Rely on out of pocket payments at point of care Very unregulated, left to free market Most low-income countries

Many commonalities among countries in how ppl see health care

Basic principles of govt financed health systems They spell out underlying values of health systems in all industrialized countries (minus US) societal values shape health systems Comprehensiveness: large set of benefits, broad perspective of what health is and it isnt Universality: everyone should have access to health care benefits Solidarity/Equity: country does not tolerate social disparities (race, income, social advantage or disadvantage) in health care o o o Everybody should have a equal/ fair shot at good health Minimize barriers make health outcomes similar Healthy people have a stake in those who arent healthly (solidarity)

Portability: you can carry it with you, health care is not linked to where you live Accessibility and affordability: services should be free/reasonabily priced, you should be able to get to care Choice of providers: you have a choice of where to go, you arent locked in

How US differs Issues with solidarity do we really owe it to the poor to pay their premiums (aka ACA) We are not sure whether every person should be covered by health insurance o Health insurance is in the personal sphere UK: equity and solidarity Law of inverse care: the availability of good medical care tends to vary inversely with the need of the population served Hart: looked at the access a poor person (who is usually sicker) has to health care compared to a rich person 1948: NHS video People were not really sold on idea of universial care Video made the case for it o o o ACA Overlap of ACA and European Basic Principles ACA is US attempt to close the gap in health care inequality Bill of rights for health care our notion of health care system is rooted in what we think as a country like our distain for socialism Governance and financing (across rich countries) international dollars adjusting for purchasing power US = highest spender, Norway = second highest spender even if you are wealthy, there are some things that you still wont be able to pay for this plan will include your family members (your wife, son, daughter) drugs, doctors, newest technologies will be available to you!

Why? Potential cost drivers Newer/more expensive technologies Our prices are higher Utilization issue

Main approaches to financing o o Tax based everybody pays taxes, it goes into the health fund (can be national (UK) or regional (Canada)) Social insurance regionally defined associations o Not tax based system Contributions to sickness funds payers, purchasers, or both Mandatory participation; opt out for high income Same comprehensive benefits for all members (equity/solidarity) Choice of providers/ sometimes sickness funds Mixed (private, public)

OECD countries Taxes: UK, Canada, Denmark, Norway o Canada: single payer health care system Social insurance: France, Germany Mixed: US, Switzerland o US multi-payer health care system

UK NHS Structure Most money goes to primary health trust (80% of every dollar spent) o o Primary care doctors in charge of the money Money is not going to specialists in effort to minimize special/ unneccessary care

Lecture 3: Health systems in high income countries 11/1912/12/2012 1:2

What does the NHS trust do? UK vast majority of $ for trust comes from taxes central government collects money and sends them to these trusts NHS are purchasing services o o Based around certain geographic areas- different NHS trusts for different areas How much money they get depends on # of people and disease profiles What are the implications of the primary case fund holding for volume of care and complexity of care? Gate keepers primary care doctors o Gate keeper system: way to organize care and make sure it is coordinated, helps prevent overuse of resources, cost control Ppl like the relationship they have with their family doctor o They are working on your behalf, personal relationship

Cost drivers: US Prices, we are just paying more Giving more health care o More procedures, more tests Bigger infrastructure Could be just fatter, just sicker PT population Are we at higher risk? no Do we have too many doctors? no Too much health care? No

Questions?

Higher fees paid to US physcians drive higher spending for physcian services compared to other countries Spending a lot on specialists Spending a lot on drugs

Performance (goals we have in health care) Health o o o Life expectancy and quality of life improved Healthy life years at birth; infant mortality measures Survival rates (like with cancer) keeps all comparisons similar

quality of care: we want happy PTs

o o

faster, more proximal metric of how a health system is doing how we measure quality of care in-hospital fatality rate w/n 30 days of admission looking as chronic condition mortalities, conditions that can be controlled asthma, diabetes avoidable hospitalizations for primary care sensitive conditions

Responsiveness: able to get to care if needed, ability to mend problem financial protection: health system should protect us from bankruptcy o measuring cost related access problems in the past year o o did not fill prescription or skipped doses had a medical problem but didnt visit MD

measure if people are having serious problems paying medical bills measuring public confidence in the system (looking at income)

US take aways: Costs, health gains, equity, quality, financial protection, overall satisfication we need to improve on all the above Two approaches to improve: Rationing: constrain the growth of health care costs, but how? Price control: how would price control work? o Cutting MDs fees: unpopular idea everywhere

Which of these is feasible in our system vs other rich countries?

Lecture 4: Health systems in middle-income countries, part 1 (11/26) 12/12/2012 1:29:00 PM

Case Studies: Taiwan, Thailand See some of the same questions arise with middle income countries as high income countries: Cost containment Where do you stop with the benefits? What is inside or outside of the package?

Basic Income groups: High income countries: $12,476 or more per capita US: $35k Low income countries: $1,025 or less per capita Middle income countries Lower middle: Egypt, Ghana, Vietnam, Pakistan Upper middle: China, Chile, Brazil, Russia

See heterogeneous U5MRs causes of death in age groups = infectious disease, malnutrion Tells us that many middle health income countries have failed to complete their minimal health goals (clean water, sanitation) o o With economic development women begin having less children HIV tells us about prevention roles in country massive cost on health system to look at HIV+ people, womens education Health expenditures Health expenditures per capita vs health expenditures as % of GDP o o per capita tells about the available resources, how much money we have to play with as % of GDP spending from all sources as proportion of the total economy size of the health sector jump in expenditures between high-middle income and high! o People get rich and first thing they want is better health care

Taiwan introduced national health insurance

Semi autonomous country (with China) After Taiwan experiences huge economic growth and then decided to create national health care system Spend 7 years planning w international output was very scientific in how they system would work 41% had no insurance were paying out of pocket o o little/no private insurance to be bought on open market most were children under 15 and adults over age 65

Short story of the health sytem

Reception Public loved the program Providers, pharm companies, doctors were against NHI

Taiwan NHI Results: Increase in service use Expenditures rose sharply overall o o Revenue not enough to outweight expenditures so raised copayments Put pressure on providershospitals to reduce admissions, cut drug prices Health information system highly evolved and helps govt track utilization o Health card that tracks all individual utilization Single-payer, govt-run financing system Financed through premiums and taxes Mandatory enrollment o Risk pooling ensured and sufficient funds Service delivery private (fee for service) and public Comprehensive benefits most everything is covered No gatekepers essentially no ceilings on care o Did this bc were concerned with public acceptability

NPR clip: basic idea Population needs to be with you (regarding health care policy) o Punish govt for negatives of health care system Management and cost cost containment efforts

Countries with a single-payer helps to open up discussion on health care system 20+ visits per month, govt comes knocking on your door Cost drivers: moral hazard, absence of a gate keeper o Look at # surgeries per capita, # of MD visits per capita to see impact of no gate keeper of $$

Questions on Taiwan

Cost containment effort: restricting providers (disincentize high volume providers), stop high users (20+ visits/month), everything is centralized, control priceslike drugs, bc single payer

Thailand Formerly very poor, now lower middle income Dramatic economic growth (not as much as Taiwan) o o But has been accompanied by growing income inequality and poor health statistics Big motivation for health care system get the poor insured Thailands health financing Financing reform was very incremental o o Subsidized voluntary health insurance for near poor rural families in 1983 2001 universal health insurance to cover uninsured o everybody pays about $1 USA to bring about unity

Purchasing and service delivery models: focus on cost containment Borrowed ideas from NHS type model o What is covered for you is what is provided in your area, you leave and you pay out of pocket Gate keeper model Thailand made deliberate investments in promoting pro-poor access to health services o Focus on rural communities, took financing away from urban hospitals and provided incentives for MDs to go to rural areas

Simultaneous investment in health infrastructure o

Results: U5MR drastically reduced (steep drop) Vaccination coverage rose Outpatients visits increased 4-fold

Skilled birth attendence rose Total fertility rate dropped

Key differences: Thailand and Taiwan Quality, scope of services in Taiwan better o Wealthy of both countries hence quality and scope of services Thailand moved the money to where the people were (rural areas)

Lecture 5: Health systems in middle income countries, part II 11/29 12/12/2012 1:29:00 PM
Health system priorities in middle income countries Need to understand the determinants of health when evaluating priorities Understanding health adversities o o Low age at which they get sick in middle income countries Getting sicker sooner and dying faster

** US is an exception when it comes to health an outlier but not necessarily a good outlier Quality and safety trying to improve the experience Responsiveness ie wait times Improved efficiency Expand access and coverage Improved health (level and equity) o o Still working on preventable causes of death Working on chronic disease issue Health system priorities in high income countries

Health system priorities in middle income countries

Social and financial risk protection

Mexico expanding coverage and financial protection and essential services Because they had a progressive model, they had a control group and were able to gather better data young population good; we know people over 65 have the most health challenges a tale of two cities: rural vs urban o o o rural areas still dealing with preventable dieases high infant mortality poor health outcomes result of unhygienic living conditions, poor nutrition, lack of access to basic health care Health System Development social security scheme to insure private sector, formal, salaried workers (1943) rest of public left to fend for themselves remainder of pop relied on ministry of health clinics o o little regulation of quality out of pocket payments

undefined benefit package

Financial reform (2004) incremental approach System for social protection in health (Seguro Popular) o o o Aim to achieve universal coverage by 2010 Gradual expansionadded couple million each year Aims: o o o Increase public health spending Improve spending on cost effective interventions Protect families from excessive health spending Shift incentives to promote quality

Insurance structure Seguro Popular scheme finances personal health services; this covers previously uninsured IMSS and ISSSTE (employers) still exist Sources of funds o o level Benefits package 255 basic interventions covered plus 15 high cost interventions (HIV, cancer, etc) Govt contributes same amount for all families to the 3 insurers to promote solidarity Monthly individual premiums (ppl in poorest sector dont need to pay much; very progessive) Govt contribues tax money, employers contribute more Essential services financed by state level and high cost at national

Results: Increased utilization SP enrollees had more surgeries, more health unit visits, used more hypertension services Better coverage for hypertension, cervical cancer screening, treatment for pneumonia life saving interventions are available/ better Improved equity and coverage services Economy improved, financial protection improved (Health system is a piece of the puzzle) Challenges Geographic inequities in access Health spending too low to tackle chronic diseases

Specialist physician shortage Poor efficiency as health systems are decentralized Continued barriers to access and quality services o o Will still pay out of pocket bc the clinics dont always have necessary resources Cutting quality to expand coverage is taking its toll

Catastrophic health expenditures too much to spend on health, have nothing else for other expenditures Brazil improving quality and quityhas a more organic approach Most ppl concentrated in the south, southest, northeast which is an issue for public health Brief History Rapid economic growth, largely benefitting higher income groups o High Gini ($ in the hand of one) Complete demographic/social transition demographic dividen = moving from high fertility to low fertility See the epidemiologic transitioncauses of death shifting health declared a right without it bankrupting you (1986) o you can sue the govt now! if you dont have access to health care health financing: majority from taxes and social contributions o private and public money always add to 100% (need to think about external spending in poor countries) Like Thailand- they focused on simutaneous expansion of supply side Post health centers Specialist output services Family Health Program main strategy for health care delivery o o Primary care and referral for specialist/ hospital care gate keeper system Family health care teams (MDs, RNs, dentists, health workers) assigned to PSF clinics in geographic areas w/ 600-1k families Keys parts: o Team based care focusing on families and communities Health system development long tradition of thinking about health holistically

Primary care

o Results

Emphasis on health promotion and public health

People needing health care received treatment (well most, 93%) PSF associated w drop in childhood mortality Lack of coordination btw PSF and private providers in same area Weak supply of hospitals/specialists limits access to care Decentralized health system weak management Poor quality of care/ hospital safety issues

Challenges

China expanding coverage of services

Lecture 6: Health systems in low income countries, part I (12/3) 12/12/2012 1:29:00 PM
Low income countries and history of performance of health systems Health systems est. by colonial powers---were designed for europeans, w second tier for Africans Health infrastructure concentrated in cities Medical and nursing training were based on european models o rural areas in hands of traditional providers and local and international NGOs After independence countries struggled to maintain infrastructure and health workers Countries relied on commodity exports/ loans to pay for health systems Still much of rural population had little or no access to health care

Alma Ata effort to put basic health services forward as strategy for Health for All Structural adjustment Modest debts became huge, prices fell through the floor, debt service obligations became completely unmanagble IMF and World Bank comes in and introduces loans that were conditional on economic reforms called structural adustment programs Structural adustment programs: o Results: Govts had to reduce spending in unproductive sectors---like health o o o At the same time HIV epidemic began in southern Africa 42 poorest countries in Africa cut spending by 50% Laying off MDs and RNs to meet public service ceilings Trade liberalization, devaluation, removal of govt subsidies and price controls, cost recovery in health and edu, privatization

Govt reduced civil service numbers IRIs have encouraged govts to introduce cost recovery to manage demand and help fund health services Other results= reduced funding to health sector, collapse of drug supply and distribution programs, underinvestment in capital (infrastruture)

Health systems today: Most in LMICs characterized by:

o o o

Underfunding and understaffing Fragmentation in care (vertical initiatives, disconnect btw primary and higher level care) Poor regulation of private sector (rampant poor quality/overcharging)

Results in: o o o o o Limited access to services Poor quality of care in many health facilities Large inequities in access and quality Financial burden for health care Voicelessness by the poorest and experiencing exclusion

MDGs: fuelled dramatic rise in global development assistance for health; health system priorities in low income countries strongly influenced by global community GDR: resources coming from high income countries to low income countries o we see little investment in health systems of these helped countries, though we see increase in trends of official development assistance for health In low income countries we see external resources as % of all health spending How are countries doing (generally) Internationally, we see progress on child mortality but less on maternal health and halting spread of HIV/AIDS Gap in child morality reduction btw poor and rich countries

Tanzania External environment roads are poor and majority of population lives within 10km of a health facility Health system wide network of govt and mission health facilities all levels of health facilities are (in theory) equipped to perform deliveries o are they actually? Umm not really all maternal health services are exempt from user fees

Progress seen more in child health than any other area (infant and child mortality, and U5MR) Globally we see utilization of key maternal and child health services are inadequate

Low contraceptive prevalence rate Low IPTP for malaria Possible this could be function of: poor education, lack of awareness of benefits, cultural preferences, distance, gender inequalitieshealth system?

Tanzania: despite having access, maternal health care utilization is low!!

Women are aware of need of medical assistance and difference it can make Quality of care/ access to medical resources (like drugs/ equipment) identified as reason o o Women would rather go to pay for care they couldnt afford bc it was better (duh) Suggests, quality of care is central to users no matter what the setting (interpersonal, technical)

Ethiopia & India Both experience similar challenges but have different approaches to problemsneed to expand health systems Different approaches due to: o o o Differences in health system infrastructure India has a more educated population. higher DGP, more MDs Tradition of private care in each respective place

Lecture 7: Health systems in low income countries, part II (12/6) 12/12/2012 1:29:00 PM
Financial protection and quality of care in India Indias RSBY health insurance scheme govt run health insurance scheme for the poor (ppl living below poverty) Business model for stakeholders o o Insurers paid premium for each enrolled household Hospitals have incentives to provide treatment to larger # of ppl they are paid per beneficiary treated Quality of care in India Assessed quality by sending standardized PTs out to doctors in rural area and urban Delhi (both private and public clinics visited) o o PTs has common diseases in India (asthma, child at home w dysentery (bloody watery stool), unstable angina) Results 11% do providers in rural area had MD, hald had MD in urban area only half had postsecondary education 47% were given wrong diagnosis equipment made no difference no big difference btw private/public

implications substandard quality of care at primary care level threatens health outcomes even if we improve utilization and clinic supplies o quality of training needs to be addressed

Human resources crisis Human resources for health health workers o o Critical input into the production of health Shortage of health workers is reason for major bottleneck in scaling up health systems and health interventions Spectrum of health workers: family workers, informal workers, community workers, professionals (best) Doctors most needed in Central and Southeastern Africa and Southern Asia o o Generally just a shortage of health workers all around When they are in these areas, concentration is skewed towards cities Doctors highly concentrated in Northern America and Western Europe

Health worker dynamics how to get more workers Need inflow of education (ie training) and in-migrationthis leads to stock of health workers Stock of heath workers production of health o o We see motivation, competence (bc educated) and coverage Issue when we have an outlow (migration) of workers Outflow health profs highly mobile workforce there are many pull factors: developed countries, salaries, recruitment efforts nearly 60% of international medical grads from lowerincome countries many push factors: poor quality of life, low salaries, poor working conditions, professional dissatisfaction, high work burdens (HIV/AIDS) Maldistribution approaches Incentives for rural practice o Not just $ as seen in Ghana desire for improved infrastructure and supportive management Pool of locum physicians for temporary service Recruiting students from rural communities Bonding: pre-med school contract to serve in rural area for period of time after graduation Mozambique see a health worker crisis o o most people live in rural areas, low GNI per capita MDs left country bc of civil war (2006- only 435 MDs)

Low utilization of maternal health services in rural areas could be bc there are fewer skilled attendants compared to urban areas

Tcnicos de cirurgia program Response to health worker shortages Task shifting seen non-physician clinicians o 3 years basic medical training, 2 years practice, 3 years surgical training quality of care is pretty good (compared C-sections done by them to those by obstetriciansno difference in serious

complications...just more superficial wound separation for Tcnicos) Tcnicos in rural areas have higher retention rates than doctors Cost-effective cost of training much lower

Lecture 8: Synthesis and wrap-up 12/10

12/12/2012 1:29:00 PM

Health systems in post-conflict countries Liberia as case study Fragile states states in chronic political crisis, chronically poor governance, states of conflict or recovering conflict ex. Niger, Liberia, Afghanistan, DRC, Niger Fragile states are important b/c o o o o o 1/3 of ppl live in absolute poverty 1/3 of maternal deaths each year of children dying under age 5 1/3 of those living w/ HIV/AIDS 1/3 of ppl there are undernourished

Deaths in post and low intensity conflict countries Deaths in low intensity: not b/c of violence but due to preventable and treatable conditions (diarrhea, respiratory infection, malnutrition, malaria) Deaths due to collapse of water, sanitation, and health systems (as seen in the DRC) Health system investments begin in the transition phase (post conflict countries) Liberia Nimbia country predominantly rural, health system destroyed in war Health status malaria endemic o o o Health system Receives most funds from foreign assistance Health services largely managed by NGOs Minimally equipped clinics provide most essential care High U5MR, MMR HIV prevalence lower than many African countries Many w/ depression and PTSD Transition from humanitarian assistance to deelopment is challenging Health policies/systems not first priority of rebuilding Health systems suffer as consequence See funding gaps

**Health is only one of many challenges**

Liberias Healthy Policy

Basic package focuses on maternal and newborn health, child health, reproductive and adolescent health

Availability of resources 5 years after war there is high availability of ACT (malaria treatment) availability of HIV treatment is fairly good emergency obstetric care is poor and mental health services (about 5 places each) integrated management of childhood illness = extremely poor availability is NOT proportional to health needs o o reasons = technical and political there is a strong donor role in rebuilding health systems see lack of harmonization and resulting fragmentation of funding and projects puts additional strain on already weak govt Wrap-up of class: Major module themes 1. 2. Tension between coverage and quality Ways to improve quality of care (financial/non-financial) Efforts to improve coverage via essential services/ insurance o o o 3. Human resources for health o distribution and incentives for rural service Taiwan, Thailand, Brazil, Mexico Used in rich/ poor countries Innovative approach to improve quality A closer look at pay-for-performance System building blocks: service delivery, health workforce, information, financing Things that lead us from building blocks to outcomes: access coverage, quality, safety Goals of health systems: improved efficiency, social and financial risk protection, responsiveness, improved health large # of non-state actors operating outside govt adds to chaos in service and management

o o o o o EMRs o o o o o

brain drain task shifting/mid-level providers level of funding regressive financing financing models: single payer, social insurance, private pros and concerns feasibility of implementation Primary care approaches (e.g., Brazil) Benefits of primary care focused service delivery Gatekeeper systems

Financing

Service delivery

Rwanda drivers of success Pay for performance (P4P) o Larger effect for services with larger incentives o o P4P in US P4P paid self-selected hospitals if they performed in top 20% on mortality conditions o Not effective, improved process measures not sustained essentially no effect Drivers of failure in US Incentives focuses on process of care with outcome being a small fraction of overall score P4P Summary Could be helpful in improving provider motivation at low end quality of care spectrum Limited effects for complex conditions (as see in the US) unlikely to be holy grail for health system improvement Led to innovations: providers worked with communities to persuade mothers in deliver in facilities Larger effect for services with greater provider control Smaller effect for more complex services (complete course of immunization)