health systems: goals, functions, actors health system ... · • indicates the extent to which...

Wilm QuentinDept. Health Care Management,

Technische Universität Berlin(WHO Collaborating Centre for Health Systems

Research and Management)&

European Observatory on Health Systems and Policies

Health Systems: Goals, Functions, Actors

Health System Performance Assessment

202 October 2019 Responsiveness & Efficiency

Timetable

WHO 2007

25 Sept

25 Sept

26 Sept

26 Sept

27 Sept

01 Oct

02 Oct

01 Oct

02 Oct

02 Oct


Guiding framework for the module

30 Sept

Summary: 27 Sept Performance assessment: 03 Oct

& other frameworks: 24/25 Sept

25 Sept

Überschrift

4

World Health Report 2000

• First attempt to rank performance of 191 national health systems

• Identifies and measures performance of countries on ‘key health system objectives’

• Examines whether each health system is performing as well as it can, given existing resources

• Based on Murray & Frank framework (2000)

24 September 2019 Frameworks 1

512 April 2019 Week 1: Introduction and frameworks

Boundaries of health care systems

WHR 20006

The first health system framework = strategy behind World Health Report 2000

24 September 2019 Frameworks 1

SERVICE DELIVERY (DEL)

HEALTH WORKFORCE (HW)

INFORMATION

MEDICAL PRODUCTS (MP),

VACCINES & TECHNOLOGIES

LEADERSHIP / GOVERNANCE (GOV)

FINANCING (FIN)

IMPROVED HEALTH (LEVEL AND EQUITY)

RESPONSIVENESS

SOCIAL AND FINANCIAL RISK

PROTECTION

IMPROVED EFFICIENCY

ACCESS

COVERAGE

QUALITY

SAFETY

SYSTEM BUILDING BLOCKS OVERALL GOALS / OUTCOMES

Source: World Health Organization (WHO) (2007) Everybody’s business: Strengthening health systems to improve health outcomes. WHO’s framework for action. Geneva: WHO Document Production Services. 7

Further development at WHO (2007): “building blocks” and “intermediate goals/ outcomes”

x =

Inputs (money and/or resources) (Allocative)Efficiency

(value for money, i.e. population health and/ or

responsiveness per input unit)

Populationhealth outcomes(system-wide effectiveness,

level & distribution)

Responsiveness(level & distribution)

Access(ibility)incl. Financial protection

Quality (for those who

receive services)

Health system performance

817.07.2018 Week 13: Health System Performance Assessment

The combined performance framework (incl. cost/efficiency and relationship to WHO dimensions)

x =









receive services)




10

The access(ibility) component

Need (by socio-economic status, ethnicity/ migration status etc.)

x Quality = Outcomes (population health & responsiveness)

Unmetneed

Unmetneed

Realisedaccess

coverage (financial issues)

availability of care

waiting, acceptability etc.

WHO based on R. Busse1130 September 2019 Access and Coverage

The UHC Cube in WHO reports 2010, 2013

1230 September 2019 Access and Coverage

Does it make a difference? Importance shown usually by U.S. data; here: cost-related access problems in 2018 for U.S. adults

Notes: * Includes any of the following because of cost: did not fill a prescription; skipped recommended medical test, treatment, or follow-up; had a medical problem but did not visit doctor or clinic; did not see a specialist when needed. “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. “Insured now, had a coverage gap” refers to adults who were insured at the time of the survey but were uninsured at any point in the 12 months prior to the survey field date. “Uninsured now” refers to adults who reported being uninsured at the time of the survey.

Data: Commonwealth Fund Biennial Health Insurance Survey (2018).

11 10 117

2325 23 24

17

41

35 34 35

27

56

3236

49

29

59

Did not fill prescription Skipped recommendedtest, treatment, or

follow-up

Had a medical problem,did not visit doctor

or clinic

Did not get neededspecialist care

At least one of fouraccess problemsbecause of cost

Insured all year, not underinsured Insured all year, underinsured

Insured now, had a coverage gap Uninsured now

x

11 1114

1921 21 22 22 23

28

32

0

20

40

60

NETH UK GER SWE AUS SWIZ NZ NOR FRA CAN US

%


The benefit basket also matters: e.g. dental care

Skipped Dental Care Because of Cost in Past Year

x

Covered in basic package Complementarycoverage high

Not covered

Own elaboration based on data from 2016 Commonwealth Fund International Health Policy Survey in Eleven Countries.

1401 October 2018 Financial Risk Protection & Equity in Financing

Summary of main forms of (formal) cost-sharing

Costs of service

Co

st-s

har

ing

Fixed co-payment/user fee (e.g. 100)

Co-insurance (e.g. 20%)

0 1.000

Deductible (e.g. 100% upto 300, 0% afterwards)

x

What do we know about cost-sharing?

Argument for cost-sharing Evidence

Reduce inappropriate use?Yes, but reduce appropriateuse too: no selective effect

Contain total / public spending?

No evidence of long-term cost control: elasticity, other costs,

intensity, prices, costs driven by supply

Raise revenue? Yes, but not much

Steering?Maybe, in specific contexts: may involve removing user charges

Everyone else does itDo they? Does that make it

the right thing to do?1501 October 2018 Financial Risk Protection & Equity in Financing


Urban-rural discrepancies; measured by population survey (Afrobarometer; 36 countries 2014/15)

availability of care

57

46

40

22 23

6060

55

45

55

32 31

26

5859

50

46 47

55

39

17

30

2018

28

61

54

49 4946

41

2825 24

20 20

0

10

20

30

40

50

60

70

2005

2008

2010

2013

Waiting time (here: >4 weeksfor a specialist appointment) is a problem, but some OECD countries see improvements and others not

Own elaboration, data: Commonwealth Fund International Health Policy surveys, 2005-2013

waiting, acceptability etc.



Realised access: Inequity of physician visits byincome (and equal need); in many countries visible – and a real problem in certain ones with poor seeing GPs and rich seeing specialists

http://www.oecd.org/health/health-systems/31743034.pdf

Realisedaccess


Inequalities in unmet need due toincome by country

Unmetneed

Unmetneed

Poor 50%

Rich 50%


Unmetneed

Unmetneed

Unmet needin African countries, 2014/15 What would be your

advice to theGovernments ofLiberia and Ghana?

x =









receive services)




2201 October 2019 Quality and Safety

Levels of health care quality

Health care systemquality

Health care service quality

= Health care quality:"the degree to which health services for individuals and populations are (1) effective, (2) safe, and (3) people-centred"

= Health systemperformance (the degree towhich health systemsachieve their goals)


Combining OECD and Donabedian

Structures Processes Outcomes

Effectiveness

Safety

Responsiveness

Structures

Structures

Structures

Processes

Processes

Processes

Outcomes

Outcomes

Outcomes

Effectiveness

Safety

Responsiveness

Effectiveness

Safety

Responsiveness

Staying healthy

Getting better

Living better with illness

Coping with end-of-life

To get a sense of dimensions: DE has200.000 AMI hospitalisations / year→ 8.000 more deaths compared to NO

Effectiveness of inpatient care: AMI letalityof inpatients … during hospitalision only


In Ghana, adverse effects are highlyprevalent

Ghana

Angola

Source: IHME, GBD Compare

• Respect for the dignity of a person

• Confidentiality of information

• Participation in decision-making (autonomy)

• Clear and understandable communication

• added*: trust

Respect-for-Persons

• Choice of provider

• Prompt attention

• Quality of basic amenities

• Social support by networks (only inpatient care)

• added*: coordination and continuity of care

Client or patient orientation


What is responsiveness?An expanded version of the original WHO concept

Sources: Valentine et al. (2008) and *Röttger, J, Blümel, M, Fuchs, S, Busse, R (2014)

2701 October 2019

The major tools

Health care outcome: satisfaction, complications etc.

Structures and organisation

Patients

Process

Population health status (need)

Health gain/ Outcome

Other sectors

Nutrition/ agriculture

Environment

• Professional/provider (re-)certification

• Institutional provider (re-)accreditation

• Health Technology Assessment

• Volume and quality standards

Quality indicators

based on clinical and

adm. data, registers

& patient surveys

→ public reporting &

pay-for-performance

Human resources

Technologies

Financial resources

Health care system

• “Do the right thing“: ex ante Guidelines/ disease

management programmes; ex post Review/Medical audit

• “Do the thing right“: Quality indicators, Patient safety

• “Do the things better“: Quality improvement strategiesQuality and Safety

x =









receive services)



Mortality/

(healthy) life expecancy

Avoidable

mortality (amenable

to health care)Health care

Socio-economic

status/ education etc.

Lifestyle

Environment

Medical errors

=


How can we calculate the health system contribution to health?

Short distinction:

Amenable mortality: in the light of medical knowledge and technology at the time of death, all or most deaths from that cause (subject to age limits if appropriate) could be avoided through good quality healthcare.

Preventable mortality: in the light of understanding of the determinants of health at the time of death, all or most deaths from that cause (subject to age limits if appropriate) could be avoided by public health interventions in the broadest sense.

Avoidable mortality: all deaths defined as preventable, amenable, or both, where each death is counted only once. Where a cause of death falls within both the preventable and amenable definition, all deaths from that cause are counted in both categories when they are presented separately. .

3001 October 2019 Improved Health

Avoidable mortality

Source: ONS, 2011

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3101 October 2019 Improved Health

A similar approach, listing tracer separately and combining results in a “Healthcare Access and Quality Index”

x =









receive services)



Technical Efficiency (the easier one):

• indicates the extent to which a health system is securing the minimum levels of inputs for a given output or the maximum level of output in relation to its given inputs (ie. “doing the same at a lower cost”).

Example: unit costs measured by average length of stay

Allocative Efficiency:

• indicates the extent to which limited funds are directed towards purchasing an appropriate mix of health services or interventions that maximize health improvements (ie. “doing the right thing, at the right place”)

Examples: distribution of health spending by provider; share of generic prescribing


Two types of efficiencies

2017

2015

2015

2015

2016

2015

2015

2015

2016

2016

50

60

70

80

90

100

110

120

130

2.0

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2.2

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2.5

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2.7

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3.0

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3.2

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3.7

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current health expenditure, US$ PPP, per capitaAustria Denmark France Germany Netherlands UK Switzerland Belgium Sweden USA

Calculating efficiency of system I: Amenable mortality (a health outcome indicator), cross-sectional and longitudinal vs. costs

34

Decrease in avoidable mortality per 100.000 persons aged 0-74, 2005-2015:

France -18


2017

2015

2015

2015

2016

2015

2015

2015

2016

2016

50

60

70

80

90

100

110

120

130

2.0

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2.2

50

2.5

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2.7

50

3.0

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3.2

50

3.5

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3.7

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4.0

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4.2

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4.5

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4.7

50

5.0

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5.2

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5.5

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5.7

50

6.0

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6.2

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6.5

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6.7

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7.0

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7.2

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7.7

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8.2

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8.7

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current health expenditure, US$ PPP, per capita

Austria Denmark France Germany Netherlands UK Switzerland Belgium Sweden USA

35

Incremental cost-effectiveness (death rate decrease per $1000 spent more, 100.000 persons aged 0-74, 2005-2015):

France: 18 / 1.55 = +11.7

Calculating efficiency of system II: Amenable mortality (a healthoutcome indicator), cross-sectional and longitudinal vs. costs


• refers to in how far people are protected from the financial consequences of illness

• is achieved when payments made to obtain health services do not expose individuals to financial hardship and do not threaten living standards

• Is closely related to

coverage

Financial protection



Catastrophic health spending worldwide

Impoverishing and catastrophicexpenditures on health

Saksena P, Hsu J, Evans DB (2014) Financial Risk Protection and Universal Health Coverage: Evidence and Measurement Challenges. PLOS Medicine 11(9): e1001701. https://doi.org/10.1371/journal.pmed.1001701http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001701

High correlation betweencatastrophic expenditure

and impoverishing spending


http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001701


OOP expenditures as fraction oftotal health expenditures, 2014

Source: World Health Statistics 2017

Low income

Lower middle income= countries with highest OOP

Uppermiddle income

High income

India

China

progressive

proportional

regressive

income

health

funding

= equitable = „good“

= not

equitable

= „bad“

= „not so

good“

Equity in financing

Progressive: individuals withgreater abilitycontribute a larger proportion of theirincome than do individuals with lowerability to pay

Regressive:individuals withgreater abilitycontribute a lowerproportion of theirincome thanindividualswith lowerability to pay


• to make health systems “high-performing”, we need to agree on what we mean,

• how we define and measure “performance” with its various dimensions, and

• who will be responsible for which component.

• Managing for improvement should always take a population-/system-perspective (rather than looking at patients only), and

• costs per “performance improvement” should be considered as well.


In summary

health systems: goals, functions, actors health system ... · • indicates the extent to which...

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