Future health system challenges Myths and Realities

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Future health system challenges Myths and
Realities

• Copenhagen, 5th October 2009
• Josep Figueras

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The four horsemen of the Health Systems (HS)
Apocalypse
- Famine population ageing causing resource
scarcity in HS - Pestilence the unwanted spread
of technology - War by citizens placing
unreasonable expectations on HS - Death
financial (un)sustainability of universal HS
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Increasing expenditure Economic recession Cost
containment Financial sustainability!
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Is it the end of the welfare State?
From I. Kickbush
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Financial sustainability But what does it
mean?

• Fiscal sustainability?
• Affordability?
• Macro-economic formula?
• Need to trade off with solidarity?
• Cost containment?
• Or efficiency?

• It is not a policy goal in itself
• 1. What is the right level of funding?
• Societal solidarity / willingness to pay
• Investing in health / opportunity cost
• 2. What is the appropriate level of coverage?
• 3. How to ensure value for money?
• Improving performance

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Making the case for investing in
health systems

• The Health and Wealth debate
• The Lisbon agenda (competitiveness/cohesion)
• EU Health Strategy Together for health 2007
• WHO EURO Ministerial Conference, Tallinn, 2008

• Towards a new paradigm?
• From a drain on resources to an investment?
• From a spending to a productive sector?
• But how to make the case to the MoF?

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Investing in health systems
Health Systems
Wealth
Health
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1. Health, wealth and societal wellbeing
Health Systems
Societal Well-being
Wealth
Health

• Effects of ill health on economic growth
• Direct contribution on to societal well being

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2. Direct contribution to the economy
Health Systems

• Economic size
• Labour market
• Innovation / RD

Societal Well-being
Wealth
Health
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3. Impact of health systems
Health Systems

• Improving performance
• Measurement
• Transparency
• Accountability

Societal Well-being
Wealth
Health
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Does this hold under the recession?!

• Threat to health systems?
• Indiscriminate cross cutting
• Further ration health budgets
• Or opportunity to reform?

A. Greenspan
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Oslo - ministerial meeting12 Recommendations
3. Invest in health to improve wealth
protect health budgets 4. Every minister is
a health minister 5. Protect cost-effective
public health primary health care services 6.
Ensure more money for health and more health
for the money 8 . Ensure universal access
to health services 9. Promote universal,
compulsory and redistributive forms
of revenue collection 10. Consider
introducing or raising taxes on tobacco, alcohol
sugar salt
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Economic crisis health systems response

• Economic investment on health systems
• Component of stimulus packages hospitals, health
  employment
• Protect the health budget / raise additional
  resources
• Demonstrate Health and Wealth, scope for sin
  taxes,..
• Ensure access for the most vulnerable
• Strengthen insurance coverage, target services /
  benefits
• Prioritise/reallocate resources cost effective
  interventions
• PHC, Communicable diseases, PH, Health in All
  Policies,....
• Improve performance value for money
• Implement reforms on payment, delivery, .

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The ageing of the population The price of
success?

• An ageing crisis?
• Compression of morbidity
• Longer and healthier life expectancy
• "Living longer and dying faster
• Reduced cost of dying at older ages
• Lower life time health costs by the healthier
• Drawing less from health services
• Contributing for longer late retirement

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Addressing population ageing

• Strengthen health system response
• Improved management of chronic conditions
• Coordination / integration of care
• Focus on primary prevention (tobacco, alcohol,..)
• Support healthy ageing e.g fall prevention
  programs
• Support economic and social integration
• Increased labour participation
• Raise the retirement age
• Support social engagement

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Technology medical progress Value for money vs
cost containment

• Increases in cost effectiveness (CE)
• Improved effectiveness, (often) lower unit costs
  e.g. peptic ulcer substitution e.g. keyhole
  surgery
• But augments overall costs (even when CE)
• Extended scope/range of treatments unmet need
• Decreases cost effectiveness inappropriate use
• Indications with low marginal benefit,
  duplication
• (perverse) supply and demand side incentives
  payment systems, clinical/ consumer pressure
  groups

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Address technology medical progress

• Strengthen HTA criteria but also focus on
• Interface between HTA clinical / policy making
• Emphasis on appropriate use
• Aligning decisions with incentives (payment)
• Stakeholder involvement central to appropriate
  uptake

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Citizens expectations
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Citizens expectations

• Responsiveness (to legitimate citizen
  expectations)
• Central health systems goal in its own right
• Increased expectations benchmarking across EU
• But what is meant by it?
• Responsiveness (WHO WHR 2000), satisfaction
• How to measure it?
• Eurobarometer, satisfaction surveys, consumer
  index
• How to address it?

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Citizens expectations

• Measurement complexities e.g culture
• Role of vested interests
• Putting it into practice (e.g. choice)
• In theory choice increases quality and
  efficiency
• In practice users ignore information on
  performance
• Are the trade offs well understood?
• Responsiveness (e.g. choice) vs efficiency?
• Responsiveness (e.g. choice) vs equity?

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Addressing citizens expectations

• Improve quality of assessments
• Ensure transparency measurement and decision
• Encourage public debate on legitimate trade offs
• Focus on cost effective interventions
• E.g. staff training,
• Ensure informed citizen decision making

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The Phoenix Bird of National Health Systems

• Financial sustainability to appropriate health
  investment
• Ageing strengthen health system response
• Technology cost effectiveness appropriate use
  
• Citizens allies / co-producers of care