Monitoring Health System Reform in China: An OECD perspective

Transcription

1 Monitoring Health System Reform in China: An OECD perspective Michael Borowitz Health Division Organisation of Economic Cooperation and Development 1

2 Governance Financing WHO framework: inputs-outputs-outcomes Monitoring & Evaluation of health systems reform /strengthening A general framework Inputs & processes Outputs Outcomes Impact Indicator domains Infrastructure / ICT Health workforce Supply chain Information Intervention access & services readiness Intervention quality, safety and efficiency Coverage of interventions Prevalence risk behaviours & factors Improved health outcomes & equity Social and financial risk protection Responsiveness Data sources Administrative sources Financial tracking system; NHA Databases and records: HR, infrastructure, medicines etc. Policy data Facility assessments Population-based surveys Coverage, health status, equity, risk protection, responsiveness Clinical reporting systems Service readiness, quality, coverage, health status Vital registration Analysis & synthesis Communication & use Data quality assessment; Estimates and projections; In-depth studies; Use of research results; Assessment of progress and performance of health systems Targeted and comprehensive reporting; Regular country review processes; Global reporting 2

3 Outcomes: shift towards more specific outcome measures to measure health care system Millenium Development Goals Infant mortality, child mortality, maternal mortality (TB, AIDS, and Malaria). Life expectancy is best synthetic measure Life expectancy at 65 is good for measuring health care for the elderly, the fastest growing population in OECD Amenable mortality: attempt to isolate the mortality that can be influenced by the health system Outcomes measures for chronic diseases: cardiovascular, cancer, mental health Adding quality as an outcome 3

4 Outcomes: Life expectancy at birth,1970 and 2008 Years (or latest year available) Japan France Korea UK OECD US Malaysia China Asia India Source: OECD Health Data 2010 and The World Bank, World Development Indicators Online. 4

5 Outputs: Amenable mortality: Mortality that can be affected by effective health system intervention Standardised mortality rates per population US OECD UK Korea Germany Canada Japan Italy France Note: Nolte and McKee list. Source: Data extracted and calculated from the WHO Mortality Database. 5

6 Outcomes for chronic diseases: Cardiovascular disease, mortality rates Age-standardised rates per population Asia China Malaysia OECD US UK Korea France Japan Source: WHO Global Burden of Disease,

7 Effects of epidemiological transition Shift from infectious disease to chronic diseases Low infant, child, and maternal mortality Ageing population Increasing importance of morbidity Need for coordinated care between primary care, hospital care, and longterm care 7

8 China is developing epidemiological pattern of other OECD countries Major causes of mortality and morbidity Cardiovascular disease Cancer Mental health External causes: traffic accidents 8

9 The Overall Goal of the Health Care System Reform Establish and improve the basic health care system covering urban and rural residents, and provide the people with secure, efficient, convenient and affordable health care services. By 2011, the accessibility to the basic health care services shall have been improved markedly, residents burden of medical costs shall be effectively reduced, and the problem of difficult and costly access to health care services shall have been remarkably relieved. By 2020, the basic health care system covering urban and rural residents shall have been fundamentally established. Everyone shall have access to the basic health care services, the multi-layer demands of people for basic health care services shall be met preliminarily, and the health level of people shall be further enhanced. 9

10 5 Areas of Chinese Health Reform Financial Protection/social security Health insurance coverage, out-of-pocket spending Service delivery Primary care, hospital care Hospital Reform Hospital efficiency: quality and cost Drugs Prices/quantity/generics Public Health Risk factor reduction for chronic diseases 10

11 Health Insurance Measuring coverage 11

12 Outputs: Access to Care and system responsiveness Access to care Coverage Out of pocket spending /catastrophic Coverage of effective interventions: Percentage of population who received effective intervention Responsiveness Patient satisfaction Patient rights Information Choice (e.g. Public league tables of provider performance) 12

13 Health Insurance coverage: Having insurance is not the whole story People can be covered by health insurance, but what is the Scope and Depth of coverage? Scope Scope of benefits package Depth Outpatient drugs? Mental health? Financial protection Deductibles, co-payment What is level of out-of-pocket spending Are households protected from catastrophic expenditure 13

14 Outputs: Most OECD countries have Universal Coverage Total public coverage % of total population Primary private health coverage Canada Italy Japan Korea UK France Germany US Source: OECD Health Data

15 Outputs: Differences between OECD countries in financial protection measured by out-of-pocket spending for essential care 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Source: SHA OECD estimates 15

16 Service Delivery Measuring quality 16

17 Health Care Quality Indicators Largest international effort to track health care quality indicators. Subgroups working on patients safety, responsiveness, etc Examples of indicators: survival rates after heath attacks, stroke, cancer. Health system indicators Primary care sensitive conditions 17

18 Avoidable admissions Requires primary/secondary care coordination Can measure effectiveness of primary care Also linked to incentives in hospital system Is there primary care gate-keeping? Do hospitals have incentive to admit? Good measure of health system performance 18

19 Diabetes admissions: good measure of primary care Diabetes acute complications admission rates, population aged 15 and over, Does not fully exclude day cases. 2. Includes transfers from other hospital units, which marginally elevates rates. Source: OECD Health Care Quality Indicators Data 2009 (OECD). 19

20 Amputation: good indicator of diabetes care Diabetes lower extremity amputation rates, population aged 15 and over, Age-sex standardised rates per population United States1 (2006) Spain Portugal Belgium (2006) Denmark Switzerland (2006) OECD France Sweden New Zealand Netherlands (2005) Canada Finland Norway Poland2 (2006) Italy (2006) Ireland United Kingdom Korea Austria (2006) Female Age-standardised rates per population 51 Male 1. Does not fully exclude day cases. 2. Includes transfers from other hospital units, which marginally elevates rates. 20

21 Asthma is an avoidable admissions Asthma admission rates, population aged 15 and over, Does not fully exclude day cases. 2. Includes transfers from other hospital units, which marginally elevates rates. Source: OECD Health Care Quality Indicators Data 2009 (OECD). 21

22 Avoidable Admissions Asthma COPD Diabetic acute complications CHF United States1 United Kingdom Austria Belgium Canada 1 Switzerland Denmark Sweden Finland Spain Germany Poland2 Iceland Norway Ireland New Zealand Italy Netherlands3 Korea 22

23 Hospitals Measuring quality + efficiency 23

24 Efficiency: Average length of stay for acute care Days Japan Korea (95-03) Germany Canada UK Italy OECD US France Source: OECD Health Data

25 The specific case of cardiovascular disease Differences in mortality are due to: Differences in prevalence of the disease Risk factors Primary risk reduction: largely social determinants Secondary risk reduction: health system sensitive Survival of these with acute episode: heart attack, stroke, etc. Admission rates are health system sensitive 25

26 Outcomes: Cardiovascular disease, mortality rates Age-standardised rates per population Asia China Malaysia OECD US UK Korea France Japan Source: WHO Global Burden of Disease,

27 Cardio-vascular: Congestive Heart Failure CHF admission rates, population aged 15 and over, Age-sex standardised 400 rates per population 0 Poland1 (2006) United States2 (2006) Germany Austria (2006) Italy (2006) Finland Sweden France OECD Spain New Zealand Iceland Ireland Norway Portugal Netherlands3 (2005) Belgium (2006) Denmark Switzerland (2006) Canada Japan (2005) United Kingdom Korea Female Male Age-standardised rates per population Includes transfers from other hospital units, which marginally elevates rates. 2. Does not fully exclude day cases. 3. Includes admissions for additional diagnosis codes, which marginally 27 elevates rates.

28 Measure of Hospital Effectiveness: 30 Day Hospital Mortality for heart attack

29 Cancer outcomes: good measure of health system outcomes Cancer mortality versus 5 year survival Mortality includes risk factors Survival is health system effect Measuring cancer survival requires Population-based cancer registry Accurate data on cancer staging on diagnosis Some cancer registries in China Population registries useful for key chronic diseases 29

30 Cancer survival rates Cervival cancer Five-year relative survival rates Breast cancer Note: Survival rates are age standardised to the International Cancer Survival Standards Population. 95% confidence intervals are represented by H in the relevant figures. 30 Source: OECD Health Care Quality Indicators Data 2009 (OECD).

31 Indicators for mental health Hospital indicators for severe and persistent mental illness Schizophrenia, major depression Primary care indicators for treatment of mild to moderate depression and anxiety disorders. Community based support for schizophrenia Public health interventions for mental health 31

32 Mental health Unplanned schizophrenia re-admissions to the same hospital, Finland Sweden Denmark Norway Ireland OECD (12) Belgium (2006) New Zealand Canada (2005) Italy (2006) Spain United Kingdom Slovak Rep. (2006) Female Male Age-sex standardised rates per 100 patients Age-standardised rates per 100 patients 32

33 Drugs Access, quality, and efficiency 33

34 OECD spending on Drugs varies widely Annual pharmaceutical spending per head, US$ FRA 800 ESP USA SVK AUS JPNSWE ITA CAN DEU GBR ISL PRT AUT FIN KOR NLD HUN IRL CZE DNK CHE NZL POL NOR LUX MEX National income per head, US$ (purchasing power parity exchange rates) Source: Pharmaceutical Pricing Policy in a Global Market, OECD,

35 Pharmacetical expenditure as % total health expenditure Pharmaceutical expenditure as % GDP Health systems differ widely in how much they spend on drugs Pharma. Expenditure as total health expenditure (left hand scale) Pharma. Expenditure as % GDP (right hand scale)

36 Average annual growth rate, Drug spending has slowed in many OECD Countries 20% 15% Average annual growth rate in real pharmaceutical expenditure, Average annual growth rate in real total health expenditure, % 5% 0% -5% 36

37 Share of funding (%) Public spending on drugs: Many OECD countries cover most costs % public funding % private health insurance % out-of-pocket payments % overall private funding

38 Generic penetration in OECD countries: wide variation in cost-savings approach 38

39 OECD reimbursement policies for drugs Most OECD countries do not regulate the prices of over-thecounter (OTC) medicines not covered by health insurance Most OECD countries regulate the price or reimbursement price of outpatient prescription drugs covered by health insurance to address well-known market failures using three main instruments: international benchmarking, therapeutic benchmarking economic assessment. Payers and pharmaceutical companies have developed productspecific pricing agreements to link the value brought by a new product in terms of health gain, to the unit price or, to limit budget impact. 39

40 Public Health Reducing risk factors 40

41 Non-medical determinants: Tobacco use higher in China than in OECD countries. Adults smoking daily, 2006 Males Females 57 China 3 47 Korea 5 42 Malaysia 2 41 Japan Asia 6 31 France OECD India 3 23 UK US % 20 0 Sources: OECD Health Data 2010; WHO, % 41

42 Non-medical determinants: Alcohol consumption Population aged 15 years and over, 2005 Litres per capita France UK OECD Japan US Korea China Asia Malaysia Sources: WHO, 2010; WHO Global Information System on Alcohol and Health (GISAH); OECD Health Data

43 Non-medical determinants: Increasing obesity rates % US Australia UK China Korea Japan Sources: OECD Health Data 2010; WHO Global Infobase. 43

44 Outcomes: Prevalence of diabetes, 2010 (increasing rapidly in China) % Adults aged years Malaysia US Korea India France OECD Japan China UK Note: The data are age-standardised to the World Standard Population. Source: International Diabetes Federation (2009), Diabetes Atlas, 4 th edition. 44

45 Many public health interventions and health system interventions Treatment of hypertension Treatment of high cholesterol Treatment of diabetes Smoking cessation services Counselling for obesity Treatment of mild depression and anxiety disorder 45

46 Health system efficiency Measuring quality + efficiency 46

47 Approaches to efficiency Whole system efficiency Outputs per spending Sub-system efficiency Hospitals (e.g. length of stay) Primary care (preventable admissions) Pharmaceuticals Clinical subsystems Cancer, cardiovascular disease, etc. 47

48 OECD analysis of whole system efficiency Process: Commissioned by Ministries of Finance Joint project with Economics Department Large differences between OECD in what they achieve for their health spending Shows scope for considerable improvements in health without increased spending 48

49 Social Determinants Have A Large Effect On Population Health Gains in life expectancy At birth At 65 Female Male Female Male Explained by: Years Deaths/1000 live births Per cent Health care spending Smoking Alcohol Diet Pollution Education GDP Memorandum item: Decline in infant mortality rate Observed changes Memorandum item: changes Source: Joumard, André, Nicq & Chatal (2008), «Health Status determinants: lifestyle, environment, health care resources and efficiency», OECD Economics Department Working Paper No

50 Measuring Efficiency: Efficiency Frontier Is Based On Best Performers 50

51 Measuring Efficiency Results and Robustness (with Different Indicators for the Outcome) Source: Joumard, André & Nicq (2010), «Health Care Systems: Efficiency and Institutions», OECD Economics Department Working Paper No

52 Health Systems Characteristics Country Clustering Reliance on market mechanisms in service provision Mostly public provision and public insurance Private insurance for basic coverage Public insurance for basic coverage No gatekeeping and ample choice of providers for users Gatekeeping Private insurance beyond the basic coverage and some gatekeeping Little private insurance beyond the basic coverage and no gatekeeping Limited choice of providers for users and soft budget constraint Ample choice of providers for users and strict budget constraint -1- Germany Netherlands Slovak Republic Switzerland Australia Canada Belgium France Austria Czech Republic Greece Japan Korea Luxembourg Iceland Sweden Turkey Denmark Finland Mexico Portugal Spain Hungary Ireland Italy New Zealand Norway Poland United Kingdom Source: Joumard, André & Nicq (2010), «Health Care Systems: Efficiency and Institutions», OECD 52 Economics Department Working Paper No. 769.

53 The Link Between Efficiency And Health Policies Source: Joumard, André & Nicq (2010), «Health Care Systems: Efficiency and Institutions», OECD Economics Department Working Paper No