Lessons from the

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Lessons from the Canadanish experience
Lieven Annemans
Universiteit Gent, VUB
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Content

1. Recommendations for improved health (care) policy
   (VGR)
2. Similarities and differences with Can/Den
3. Towards a blueprint for a Flemish health system
4. Objections against decentralization
5. Final thoughts

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Recommendations for health (care) policy

• Setting health objectives
• According to population needs
• Increase focus on prevention
• Revise the way health care providers are paid
  mix of payment
• per practice, per patient, per service, for
  quality
• Improve cost-effectiveness of interventions in
  health
• Better alignment (between prevention and cure
  between health and social services, between
  health and socio-economic status,...)
• Adapt education of health care providers to
  societal challenges

VGR , 2006
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Recommendations for health (care) policy

• Setting health objectives
• According to population needs
• Increase focus on prevention
• Revise the way health care providers are paid
  mix of payment
• per practice, per patient, per service, for
  quality
• Improve cost-effectiveness of interventions in
  health
• Better alignment (between prevention and cure
  between health and social services, between
  health and socio-economic status,...)
• Adapt education of health care providers to
  societal challenges

VGR , 2006
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? why further decentralization?

• More efficient health objectives (also including
  cure and care)
• Payment in function of quality and meeting
  objectives
• Alignment
• Between health and social services
• Between prevention and cure
• Between health and education, work and housing
  (determinants of health)
• Between health and training of health
  professionals
• Better guarantees for integrated care
• Avoid blaming, cost shifting, overlap,
  contradictions, inefficiency, double use, gaps,
  .... existing in current semi-decentralized
  situation

VGR , 2006
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Content

1. Recommendations for improved health (care) policy
   (VGR)
2. Similarities and differences with Can/Den
3. Towards a blueprint for a Flemish health system
4. Objections against decentralization
5. Final thoughts

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Similarities and differences with Can/Den

• Similarities
• Federal state - regions - subregions
• (Socio)economic differences between regions (Can)
• Language issue (Can)
• Health insurers (Can)
• Differences
• Only decidecentralized
• Cultural differences stronger (cfr J. De
  Maeseneer)
• Bismarck system (social insurance)
• Brussels

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Content

1. Recommendations for improved health (care) policy
   (VGR)
2. Similarities and differences with Can/Den
3. Towards a blueprint for a Flemish health system
4. Objections against decentralization
5. Final thoughts

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Towards a blueprint for a Flemish health system

1. Financial and political accountability
2. Spending power
3. Full responsibility for programming, norms and
   quality
4. Integration of prevention, cure and care, and of
   first, second and third line (double integration)
5. Alignment with social services and other
   determinants of health
6. Central role of the general practioner as
   gatekeeper (cfr WHO)
7. Three-layer health care system
8. Maintaining solidarity, at least for a well
   defined and agreed period of time
9. Maintain some functions at the central level
   (HTA, information system)
10. Respecting values of equity, effectiveness and
    cost-effectiveness

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Integrated
W. De Meester, 2005
Cfr RHAs, cfr LHIN in Ontario
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Solidarity? Cfr health care expenses
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Three layer health care
Regulated competitionbetween insurers
No competitionbetween insurers
W. Demeester, 1999
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Content

1. Recommendations for improved health (care) policy
   (VGR)
2. Similarities and differences with Can/Den
3. Towards a blueprint for a Flemish health system
4. Objections against decentralization
5. Final thoughts

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Objections (yes, but...)

• What about Brussels?
• Option 1 population chooses (cfr education
• Option 2 Brussels as a separate entity (own
  health challenges same size of several Canadian
  provinces)
• What about the RIZIV/INAMI?
• Transition to regional health agencies,
  responsible for steering (layer 1), regulating
  (layer 2) and facilitating (layer 3)
• Feasibility and plan to be established with
  RIZIV/INAMI top
• Cross-border care?
• Cfr. European legislation with this regard
• What about solidarity? See earlier argumentation
• Plus see Figures about affordability in Denmark
• Why not recentralizing? See next slide

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Why recentralization is less of an option

• Are we then going to recentralize social
  services, labour, education, ? If not, the same
  problems remain if yes, decreasing efficiency in
  those fields
• Regional models have succeeded in improving
  efficiency making the system more
  patient-oriented and enhancing
  cost-consciousness (Bergman, 1998)
• Centralization hinders integrated care, leads to
  information overload and being out of touch with
  providers (adversely affecting motivation, and
  makes it difficult to respond to complex local
  conditions (Mur-Veeman, 2008)
• HOWEVER limits to decentralization
• Cfr HTA in Canada (CCADTH),
• Cfr. NBOHs role in Denmark
• Cfr. Health information system in Canada (CIHI)

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Content

1. Recommendations for improved health (care) policy
   (VGR)
2. Similarities and differences with Can/Den
3. Towards a blueprint for a Flemish health system
4. Objections against decentralization
5. Final thoughts

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Final thoughts

• Decentralization is not strange nor unrealistic
• Whatever the approach, strong leadership and
  trust are required for effective planning and
  sustainability. (Stoto, 2008) (the devil lies in
  the detail)
• Two attitudes
• Decentralization as goal
• decentralization makes everything better
• Decentralization as a means
• many recommendations for improving our health
  care can be made with a decentralization, most
  of these recommendations can be better realized
  (VGR, 2006)
• Equity means solidarity based on objective
  criteria and does not mean supporting
  inefficiency (cfr unjustified overconsumption)

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Lessons from the Canadanish experienceTHANK YOU
Lieven Annemans
Universiteit Gent, VUB