Modern Health Service Delivery And Innovation: Public Procurement From The Private Sector Dr. Antonio Durán CEO, Técnicas de Salud, Spain

Transcription

1 15th European Health Forum Gastein W11 Public Private Partnership, Saturday 6 October 2012, Modern Health Service Delivery And Innovation: Public Procurement From The Private Sector Dr. Antonio Durán CEO, Técnicas de Salud, Spain

2 Where best to intervene to improve health? Work and societal organization (hierarchy, status, stress, biologic pathways) Social determinants (education, housing, nutrition, etc) Health promotion and disease prevention (lifestyles, environment, etc) Acute Medical Care (symptoms, immediate causes, etc)

3 Fight against tobacco: - some services are personal (e.g. pharmacological treatment of COPD, smoke cessation advice during consultation, etc.); - other services are non-personal (e.g. warning labels on cigarette billboards, advertising bans): - both are different from actions taken by other sectors (e.g. taxing tobacco). Duran A and Kutzin J, 2010, Financing of Public Health Services and Programs: Time to Look into the Black Box, in Kutzin J, Cashin C and Jakab M, 2010, Implementing Health Financing Reform; Lessons from Countries in Transition, WHO on behalf of the European Observatory on Health Systems and Policies,

4 HEALTH SYSTEMS FRAMEWORK FUNCTIONS THE SYSTEM PERFORMS OUTCOMES OF THE SYSTEM I N P U T S Stewardship (oversight) Financing (collecting, pooling and purchasing) Creating resources (investment and training) Service delivery (provision) Effective coverage Productivity Duran A, Kutzin J, Martin-Moreno JM and Travis P, (2011) Understanding health systems: scope, functions and objectives, en McKee M and Figueras J (eds.) Health Systems: Health, Wealth, Society and Well-being. Maidenhead, Berkshire: Open University Press and McGraw-Hill, pp Health (level and equity) Financial protection and fair distribution of burden of funding Responsiveness (to people s nonmedical expectations) Efficiency

5 Focusing services on the health and wellbeing of persons and entire populations while allowing managers and leaders autonomy to innovate and develop new ways of working is the most realistic way to overcome contemporary health challenges

6 And the effort is worth! Indicators related to health services explain between 44% and 57% of variance in life expectancy as a measure of health (the rest is attributable to non-medical determinants of health) Arah OA et al, 2006, Conceptual framework for the OECD health care quality indicators project. International Journal of Quality Health Care,18(Suppl.)1:5-13

7 Thesis: The private sector may play a key role in the modernisation of most European health care systems as long as proper regulation and management improvements are provided. Nationalisation Vs privatisation of health services discussions should be replaced by a productive debate on the appropriate role of the private sector and the degree of regulation and improved management inextricably tied with it.

8 Three reasons: First, in economic terms, most health services are rival private goods (as different from public goods and quasi-public goods ). Many public health programs include almost exclusively personal services rather than public heath, population-based services (e.g. treatment and even prevention- of TB, AIDS, STDs, etc).

9 Examples of private-goods public health services against NCDs: - screening of risk factors, - clinical consultation for prevention of NCDs, - weight reduction programs, - treatment modalities for smoking cessation. No mutually exclusive, simplistic correlation is being proposed here, but it is worth noting that historical reasons of the building of social peace and concentration of capital explain most state Vs private sector patterns and roles in health and healthcare in different parts of the world.

10 Duran A and Kutzin J, 2010, Financing of Public Health Services and Programs: Time to Look into the Black Box, in Kutzin J, Cashin C and Jakab M, 2010, Implementing Health Financing Reform; Lessons from Countries in Transition, WHO on behalf of the European Observatory on Health Systems and Policies, The WHR 2000 made the distinction in order to promote efficiency In health services, who benefits? is not the only key question. How the service is organized and delivered is also crucial (it tells about the potential roles of the public and private sectors)

11 Improving efficiency is in many countries a more rational decision than increasing health expenditure OECD countries: halving the efficiency gap (difference between the LEB they get and that of the best performing country at similar level of spending, considering also socioeconomic and lifestyle factors) would achieve the same 1 year of LEB gain as a 30% increase in expenditure Joumard I, Andre C and Nicq C, 2010, Health Care Systems: Efficiency and Institutions, Economic Department Working Paper n. 769, OECD, Paris, e=eco/wkp(2010)25

12 Real health expenses growth: per capita, 4-fold; % of GDP from 6 to almost 12; by 2030 extra 3% projected Health expenditure in 27 advanced economies Percentage of GDP (weighted by PPP) Períodos de aceleración Private Public Coady D and Kashivase K, Public Health Spending: Past Trends; and Soto et al, New Projections of Public heakth Spanding , in Clements, B, Coady D and Gupta S, 2012, The Economics of Public Health Care Reformmin Advanced and Emerging Economies, Presentation at PAHO, IMF, Washington, and 36-54

13 Second, issues of flexibility: Innovation in health services requires investors able to cope with long term risk. In the context of technological innovation, ageing and increased demand, public service management is proving impossible in the current configuration of service delivery facilities!

14 Never seen before! Politicians Citizens and users Competing providers Media Cost pressures Staff Local authorities Autonomy Legitimacy/ Status Financing Accountability Decision Capacity Improved Performance Industry Saltman RB, Durán A and Dubois HFW (eds.) (2011) Governing Public Hospitals, Reform strategies and the movement towards institutional autonomy, London: WHO on behalf of the European Observatory on Health Systems and Policies

15 Third, this is also an issue of pragmatism. The limits to direct state provision of health care are marked by the limited investment capacity of governments (in particular now with the tight budgets and fiscal crises). In short, it is very unlikely that Europe will be able to fund the required capital investment as they did in recent decades.

16 140 Debt coefficients in advanced economies, Public debt, percentage of GDP 120 Big Recession 100 Second World War Advanced economies Emerging economies Clements, B, Coady D and Gupta S, 2012, The Economics of Public Health Care Reform in Advanced and Emerging Economies, Presentation at PAHO, IMF, Washington

17 A free market in health (private finance and provision) will not yield an efficient result because of market failures ; But governments also fail (e.g. populism above efficiency and consumer satisfaction, poor planning, low implementation and supervision capacity, corruption, rentseeking behaviour, capture by lobbies, etc)

18 European Governments, need for a more rational make or buy decisions concentrating on what they do better: financing and regulation. - Funding should be mostly public in order to promote equity and access. - The stewardship function should be public but involving stakeholders and professionals much more transparently. - The creation of inputs may be substantially (but never only) private.... But Service Provision may be privatised extensively if socially agreed and if adequate regulation is provided.

19 In many European societies, public and private issues are highly political and have emotional implications; issues need to be discussed in a very prudent way. Yet as Julian LeGrand put it, theoretical problems remain, mostly involving patient information, but there are theoretical problems with state systems as well mostly involving the paucity of incentives. Julian Le Grand, 2012, London School of Economics, Ttheory and evidence from the UK shows that state-funded healthcare which incorporates market-type incentives will save more lives and reduce more suffering. British politics and policy at LSE,

20 Radical changes to the delivery system (in the UK) should involve: - decommissioning outdated models of care to create resources and space for new ones to emerge; - supporting NHS organisations to innovate and adopt established best practices; and - making it easier for new providers to enter the market where this is appropriate. Ham C, Dixon A and Brooke B, 2012, Transforming the delivery of health and social care; The case for fundamental change, The King s Fund, p. ix

21 Thank you