Title: Israeli Health System Dynamics in International Perspective
1Israeli Health System Dynamics in International
Perspective
- David Chinitz, Hebrew University Hadassah
School of Public Health - Richard Saltman, Emory University School of
Public Health and European Observatory on Health
Care Systems.
2Israeli Health System Dynamics in International
Perspective
- Structure
- Values
- Politics
- Path dependency
- Policy learning
3Emphasis on Structure
- Most health reforms deal with structural issues
- Avoid tampering with underlying social values
- Avoid difficult political engagements
- Dynamics reflect path dependency and policy
learning
4Path Dependency (PD)
- History places boundaries on reform
- Inertia of previous decisions (or non decisions)
- Institutional structure
- Organizational behavior
- Organizational politics
- Punctuated Equilibrium
5Policy Learning
- Policy makers and stakeholders deliberately
adjust the goals, rules and techniques of a given
policy in response to past experiences and new
information. - Helderman et al 2005
6Structural Elements and Options
- Centralization
- Regionalization
- Markets
- Privatization
- Regulation
- Decentralization to primary health care
7Different Emphases in Different Countries
- Regionalization (Spain, Italy, New Zealand)
- Markets (UK, Netherlands, Sweden, Germany,
Israel) - Regulation (UK, Netherlands, Sweden, Germany,
France, EU) - Primary Health Care and Public Health (New
Zealand, UK, Finland, Sweden, Spain,
Netherlands)
8Structural ReformsFinance, Allocation and
Delivery
- Changes in finance relatively minor
- And only in Social Health Insurance (SHI) systems
- Allocation
- From historical to prospective budgets
- Citizen choice
- Delivery
- Vertical integration
- Shortened length of stay
9Examples
- England
- Tax based system
- Netherlands
- SHI system
10England
- The big bang of 1948 creation of the NHS
- Based on key values
- Universal
- Comprehensive
- Tax based
- Until 1992 regional structure with strong central
control - eg center establishes rules for cross boundary
care
11The 1991 NHS Reforms
- Part of trend to reduce role of government
- Convert NHS from command and control to internal
market - Purchaser/provider split
- Hospital trusts
- General Practitioner Fund Holding (GPFH)
12Adoption and Implementation of the British
Internal Market
- The blitzkreig of adoption
- The problem of occupation (implementation)
- Social and political unwillingness to let
providers close - Collegial relations between GPs and hospital
doctors - Patient choice limited
- Contracting more about accountability than
competition - Despite expectation of new efficiencies, budgets
grow (transaction costs)
13England Implementation 2
- 1997 Labor Government
- criticizes internal market, especially GPFH
- but then introduces Primary Care Groups (PCG)
- A kind of super GPFH
- Eventually became Primary Care Trusts
- renewed focus on patient choice
- more power to NHS Foundation Trusts
- plan to grow 7 in real terms by 2008.
14England Policy Learning
- Internal market lead to focus on health gain
- PCG purchasing accompanied by activities of
National Institute for Clinical Excellence - Strong recommendations regarding new technologies
- Renewed emphasis on public health and prevention
15England Structure, Learning,Values
- Structural changes reflect a degree of path
dependency - Despite regime changes, purchasing and patient
choice remain important - While structural change goes on so does policy
learning - Prioritization of various conditions
- Focus on primary health care, public health, and
prevention - Activities of NICE
- Budgetary increases under both labor and
conservatives reflects strong social value of NHS
16The Netherlands
- A pluralistic system
- Numerous public sick funds
- Private insurers
- Corporatism
- Two main values
- Solidarity
- Subsidiarity
17Dutch Health System Issues, 1980s
- Rising costs
- Strong government intervention clashed with
corporatism
181987 Dekker Recommendations
- Unify public and private insurance under one plan
- Regulated competition among sick funds
- Risk adjusted capitation for 85 of costs
- Nominal premium to be paid by citizens
- Free choice of sick fund
- Selective contracting by sick funds
19Implementation of the Dutch Reform
- Inability to unify public and private insurance
- Mergers in health insurance sector
- Sick funds only partially at risk
- Small absolute differences in nominal premiums
- Government continues to intervene to contain
costs
20NetherlandsStructure, Learning, Values
- Despite implementation problems, the vision of
the Dekker Model survives across different
political regimes (path dependency) - The model is constantly being refined
- Pharmacy cost groups, diagnostic cost groups to
capitation formula (policy learning) - Attempts to regulate private insurance reflect
the strong underlying value of social health
insurance in the Netherlands.
21Interim Conclusions
- New public management, internal market, regulated
market, patient choice appear to survive changes
of regimes. - Never implemented in full.
- Regimes have multiple agendas, policy learning
goes on. - But reforms are always incomplete.
22Evans Failure of Health Reform
- None of the recent health reforms are able to
contain costs, and maintain equity of finance and
of access. - Is a breakthrough possible? No, because
- Evans RG Journal of Health Politics, Policy and
Law, February 2005
23Evans Evidence Based Medicine Meets Sisyphus
- But while more information is better than less,
no amount of evidence on relative efficacy or
cost-effectiveness will induce providers
voluntarily to accept overall reductions in their
activity levels and incomes.
24Evans Cont.
- And in the struggle for the hearts and minds of
the general population, or even politicians,
professional assertions of needs are rarely
countered successfully with mere evidence.
25Evans on Coping
- Effective coping depends both upon the resources
of the state in terms of bureaucratic and fiscal
capability and public respect and cooperation,
and upon the degree of democratic responsiveness
of the state itself to broader public values.
26Can Israel Find a Way out of Evans Path
Dependency?
- Can we get equity and efficiency?
27The Israeli Reform
- The Big Bang National Health Insurance 1995
- Unique
- 100 of population insured by competing health
plans - No premium for standard basket
- Standard basket detailed and mandated by law
28Israel Path Dependency
- No change yet in
- Capitation formula
- Creation of hospital trusts
- Long term care
29Israel Policy Learning
- Mental health reform
- National Primary Care Quality Measurement System
- Basket of Services and Technology Assessment
- Public debate on prevention vs adding hospital
beds
30Israel Social Values
- Increasing share of private finance
- England 19 (2000, OECD 2003)
- Netherlands 35 (2000,OECD 2003)
- Israel 32 (2002, CBS 2004)
- Perhaps worsened by external shocks
31Policy Lessons
- Take advantage of policy learning
- Focus on values and not only structural reform
- Evans
- State fiscal and bureaucratic capacity
- Public cooperation
- Democratic responsiveness to values