Reforming New Zealand's health care system

In common with many OECD countries, New Zealand has been engaged in a process of reforming the nation's health care system. In New Zealand's case the reforms have been particularly far reaching and effected within a remarkably short time frame. In 1991 the policy framework was made public, and the legislation to underpin the changes enacted in 1993. Shadow bureaucracies anticipating the reforms were set up as early as 1991, however, thus allowing for the changes to be effected in advance of legislation. Thus in the space of a few years, the social security model of health care, which had been in place for over half a century, was transformed into a system characterised by managed competition. This article begins by briefly describing the social security model of health care, and its inherent problems. I go on to analyze the reforms, focusing on the problems of the previous system that the reforms were intended to address. The major planks of the new system are identified, namely the separation of purchasing of health services from provision and creating a competitive market; the distinction between “personal” and “population” health services; establishment of a core of services to which all citizens are entitled; and the integration and capping of funding for health services, and increasing cost-sharing. Of these policies, only the separation of purchasing and provision of health care and the integration of funding for health services have to date been fully implemented, the remainder having been delayed, modified or abandoned. The health care system has arguably been only partially reformed, therefore.     

Consequences of increased third-party payments for health care services.

The growth of third-party programs to pay the costs of health care has occurred in an unplanned manner. As a result, the country presently is faced with a number of uncoordinated payment programs that sometimes work against each other. While the expansion of health insurance programs has provided the financing necessary to keep our health care system up-to-date, and while such programs doubtlessly have reduced the financial barriers to seeking health care for some population segments, health insurance also has produced some problems. Generally, the contribution of health insurance to these problems is subtle and cannot be quantified. Yet, policymakers increasingly are recognizing that there are factors at work in our health care system that, if continued unabated, will exacerbate the country's health care cost problem. Many of these factors owe their existence to the socially unacceptable incentives provided by most health insurance programs. This article focuses on some of the adverse consequences of health insurance programs and indicates that the future of private health insurance depends upon how these problems are addressed.     

Reform: health care

The Italian National Health Service was established in 1978 as three-tier system, involving State, Regions, USLs (Unità sanitarie locali, Local Health Care Units). The division between the responsibility of determining the general features of health care policy and financing it, on one side (the State), and that of managing services, on the order side (Regions and USLs), was bound to lead to increasing levels of expenditure and large financial deficits. An important reform has been carried out over the last five years, aiming toward a more decentralized system, which, although still public, were based on competition among suppliers and free choice for consumers. We argue that although the reform seems to have been successful in containing public expenditure, it has left some important issues still unresolved: the relationship between patients' freedom of choice and competition among providers, and the definition of a model of rationing the bundle of health services financed by the public sector.     

Self-rated health and barriers to healthcare in Ukraine: The pivotal role of gender and its intersections

The ongoing health crisis in the Ukraine has persisted for 48 years with a clear division of gender-based outcomes as seen in the decline of male life expectancy and stagnation of female longevity. The purpose of this paper is to investigate differences in self-rated health and system barriers to health care applicable to gender and its intersections because of the differing negative health outcomes for men and women. Intersectionality theory provides an analytic framework for interpreting our results. Utilizing a nationwide sample of the Ukrainian population (N = 1908), we found that low socioeconomic status (SES) women rate their health worse than men generally and any other socioeconomic group. Yet women also face the greatest barriers to health care until older ages when the ailments of men cause them to likewise face the obstacles. In reviewing the barrier to health care scale, one barrier—that of health care services being too expensive—dominated the responses with some 52.5 percent of the sample reporting it. Consequently, the greatest problem in Ukraine with respect to health reform reported by the population is the out-of-pocket costs for care in a system that is officially free. These costs, constituting some 40 percent of all national health expenditures, affect women and the aged the most.     

The influence of institutions and culture on health policies: different approaches to integrated care in England and The Netherlands

The concept of integrated care has assumed growing importance on the policy agendas both in England and The Netherlands and elsewhere. It is characterized as health and health care-related social care needed by patients with multi-faceted needs. This article compares policy approaches to integrated care in England and The Netherlands. Differing political strategies and conditions for integrated care correspond to the dissimilarities in the institutional structure and culture of their health care systems. Health care systems are understood as specific national and historical configurations. We review the last decade's relevant policy processes, using the concepts of hierarchy, market and network. The state health care system in England relies mainly on hierarchical steering, thus creating tight network structures for integrated care on the local level. The Netherlands, with its health care system in a public-private mix, has set incentives for voluntary, loosely coupled and partly market-driven cooperation on the local level. Implications for success or failure are mixed in both configurations. Policy recommendations have to be tailored to each systems' characteristics.     

MAKING WORK INVISIBLE: NEW PUBLIC MANAGEMENT AND OPERATIONAL WORK IN CRITICAL INFRASTRUCTURE SECTORS

Based on a study of reliability consequences of New Public Management (NPM) reforms in Norwegian critical infrastructure sectors, this article suggests that the discourse of work found in NPM renders essential aspects of operational work invisible—including practices that are known to be of importance for reliability. We identify two such organizationally ‘invisible’ characteristics of operational work: the ongoing situational coordination required for keeping a water supply system or an electricity grid running, and the aggregating operational history within which this happens. In the reorganized infrastructure sectors, these crucial aspects of operational work fit poorly in market oriented organizational models and control mechanisms. More generally, our analysis contributes to the understanding of how some types of work fit poorly within the discourse of work found in NPM.     

INSTITUTIONAL LAYERING IN GOVERNING HEALTHCARE QUALITY

Since the 1980s, regulated markets and New Public Management have been introduced in the public sector across the world. How they have affected existing governance mechanisms such as self‐regulation and state regulation has remained largely unexplored, however. This article examines the origins and consequences of institutional layering in governing healthcare quality. Dutch health care, where a market‐based system has been introduced, is used as a case study. The results show that this market‐based system did not replace but modified existing institutional arrangements. As a result, hospitals have to deal with the fragmentation of quality demands. Using the concept of institutional layering, this study shows how different arrangements interact. As a consequence, the introduction of a certain policy reform will work out differently in different countries and policy sectors. Our ‘archaeological’ study in this layering can be seen as an example of how such incremental change can be studied in detail.     

The rise of risk assessment and risk management in the United Kingdom

This article examines the reform of the health care system in England in terms of the risk assessment and risk management. Three major health policies are examined, the Health of the Nation strategy, community care and the Patient's Charter. The article demonstrates that effective risk assessment and risk management is an important component of each initiative. The Health of the Nation strategy is based on epidemiological evidence on the nature of health risks and is linked to specific targets for the reduction of harm that require effective management of risks. Community care is a well established policy designed to provide long term and continuing support for vulnerable individuals in the community. With high profile incidents in the 1980s, there has been a greater emphasis on effective risk assessment and risk management, especially to protect the public. The Patient's Charter is designed to empower users of service.

Central to this strategy is informed consent. Effective empowerment depends of the provision of adequate information, especially on the risks of treatment. Although competent adults may formally be autonomous risk-taking decision-makers, their ability to assess risk and make decisions depends on having adequate information.     

Uneven geographical distribution of medical care: A Ghanaian case study

It is well known that the provision of medical care in developing countries is often very unevenly distributed geographically, and one of the most important points made in Maurice King's pioneering Medical Care in Developing Countries, [1967, Oxford University Press: East Africa] was that health facilities such as hospitals have an extremely small effective geographical range. The purpose of this article is to use new statistical data to analyse the problem of uneven distribution of medical care further, and in this way to investigate the social and cultural factors which are indirectly reponsible. The discussion is in terms of Ghana, but much of it may well have a wider relevance.     

Incomplete vertical integration in the health care industry: pseudomarkets and pseudopolicies

Most economic relationships are either arm's-length exchange transactions, each party seeking his or her own interest, or command structures, such as a firm or public agency, integrating joint efforts toward a common goal. The health care industry, however, displays a pattern of incomplete vertical integration--relationships which are neither truly arm's-length nor completely hierarchical. The doctor-patient relationship is archetypical. Physicians appear to sell services in private markets; yet they reach through the exchange process to direct the consumer-patient's utilization decisions, implicity undertaking to act in the patient's interest, and thus integrate forward. But they also integrate backward to control the public regulatory process--self-government--and some forms of insurance. The health care systems of different countries--Canada, the United Kingdom, and the United States--can be interpreted as different patterns of incomplete integration among five basic classes of transactors: consumer-patients, first-line providers, second-line providers, insurers, and governments. Each system of linkage has characteristic strengths and weaknesses. Nowhere, however, do we find a predominance of arm's-length market relationships. Where they exist, markets in health care are usually pseudomarkets dominated by one side of the transaction. The rhetoric of market relationships serves principally to obscure political struggles over shifting patterns of integration.     

Uncertainty,risk, and wealth and income distribution in peasant agriculture

An ethical justification of the market system is that while generating inequality of income distribution it nevertheless provides an equal opportunity for people to improve their material well‐being (1, p. 169). It is argued that the market system creates a society of unequals, but that it is a fluid society in which, though all may not improve absolutely and relatively, the opportunity to do so is randomly distributed through the population. In terms of economic development, this implies that within a free market framework, the distribution of the gains from growth need not be biased towards any economic class. To use a cliche, one of the justifications of a competitive market system is that there is nothing inherent in its operation which makes ‘the rich get richer and the poor get poorer’. The main barriers to economic and social mobility are thus treated as imperfections in the market—racial and ethnic discrimination, differential access to capital markets, traditional constraints on job choice, and so on.

Recently Michael Lipton has suggested an analytical framework for explaining the optimizing behaviour of peasant cultivators which challenges this sanguine view (2). His ‘survival algorithm’ implies that inherent in the market organization of economic society is a tendency for the benefits from economic development to be distributed systematically in favour of the wealthier groups in the society.

In the following section I shall summarize Lipton's hypothesis and demonstrate its implications for the distribution of wealth and income over time in the agricultural sector of developing countries. In Section III policy conclusions of the analysis are presented.     

Use of Student Interpreters to Serve Limited English Proficient Patients

Abstract

Changing patient demographics and recently expanded federal guidelines require healthcare organizations to provide improved interpreter services to limited English proficient (LEP) patients. Access to health services for LEP patients has become a controversial public policy issue in the absence of consistent payment mechanisms and policies for recipients of federal funds affected by the guidelines. The experience of one hospital in addressing these new market demands illustrates some of the administrative, policy and educational challenges inherent in healthcare service delivery to LEP patients today. This hospital uses bilingual and bicultural college students preparing for careers in health care administration as interpreters. Preliminary data indicate that this is a cost-effective arrangement that can serve as a model for other health care organizations serving LEP patients, and as an incremental, operational coping stratagem while the broader policy issues undergo further debate.     

DEVELOPMENTS IN THE PURCHASING PROCESS IN THE NHS: TOWARDS AN EXPLICIT POLITICS OF RATIONING?

The introduction of the internal market to the National Health Service in Britain marks a major change in the form of provision of health care interventions. This article reports the findings of independent research into the development of the purchasing process in eight purchasing authorities (which collectively purchase health care for 5 per cent of the population of Britain), and considers the extent to which this has led to an explicit politics of rationing in British health care. The structure and organization of purchasing organizations is described, along with their relationship with providers of health care. The ability of purchasing organizations to assess the health needs of the populations for which they purchase health care services, and their ability to influence change in the nature of the services provided, is also examined.     

The health care state in the information age

The computerization of the medical record has important implications for the governance of health care, and the importance of health care means that changes wrought there are indicative of changes in government as a whole. This paper draws on work in public policy, medical sociology and studies of science and technology, as well as on cross–national empirical research in Britain and France. It describes the recent development of information policy in health care as an exercise in state–building, realized specifically in the governance of the health professions. The paper concludes with a discussion of what is both new and not so new in the form and extent of state power which emerges.     

An Examination of Mental Health and Psychiatric Care among Older Prisoners in the United States

Despite that prisons in the United States (and other high-income countries) have witnessed an increase in the proportion of older inmates, and that prison populations exhibit high rates of psychiatric illness, there is limited knowledge on the nature of older inmates’ psychological health and use/provision of psychiatric care. The present study addresses these gaps, analyzing a nationally representative sample of 1,907 male and female older inmates (age range = 50–84 years; M = 56) housed in U.S. state and federal prisons. The results highlight: (a) the prevalence of psychological issues among older prisoners; (b) factors associated with certain mental disorders and symptoms of mental health issues; (c) the prevalence of psychiatric treatment before and during imprisonment for those with (and without) reported psychological health issues; (d) similarities and differences between male and female older inmates in relation to psychological health, factors associated with psychological issues, and the use/provision of psychiatric care. Discussion points toward recommendations for managing inmate mental health, as well as direction for further research on older inmate mental health and psychiatric care.     

Health care reform in Israel: An historical and sociopolitical conundrum

A new and comprehensive National Health Insurance Law was implemented in Israel on January 1, 1995. This major health care reform initiative culminated an effort lasting several decades to assure broad universal health care coverage for the population as a matter of national law. Issues that affected the development of the reform package included 1) the formation of sick funds that provide care to over 96% of the population as part of other powerful sociopolitical organizations, 2) the historical development of parallel private July 16, 1995 and governmental health care systems before Israel became a state in 1948 and the post-state maintenance of multiple health care delivery systems, and 3) the close interactions of health care systems and the political processes and parties of the nation. This paper describes the effects of these forces on resisting changes that were widely accepted as being necessary to expand access, control rising health care costs, and improve the efficiency of the nation's health care system.     

Allocative medicine: efficiency, disease severity, and the payment mechanism.

Health care expenditures now account for nearly 10 percent of our gross national product, the highest share ever recorded. Concerned that this represents too many resources being devoted to health care, policymakers are searching for ways to control health care expenses. These include higher coinsurance and deductibles, measures to increase market shares of health maintenance organizations, and conversion from cost reimbursement to prospective reimbursement. These measures contain many incentives for patients and providers to alter use of health care services. However, aggregate resource use may or may not be lower and more efficient under these new programs. To determine whether limited resources would be devoted to maximizing the nation's health, incentives inherent in each policy option must be examined. This article describes a classification of types of disease and medical care outputs. The framework is then used to examine incentives offered to patients and providers by three alternative payment mechanisms--capitation, fee-for-service, and payment by diagnosis--regarding types of disease treated and mix of outputs produced. This type of analysis is required to select an appropriate payment mechanism for obtaining a socially acceptable allocation of resources.     

The Political Economy of Improving Health Care for the Poor in Rural Africa: Institutional Solutions to the Principal–Agent Problem

Both governments and private for-profit markets have been disappointing in meeting the needs of the African poor for health care. NGO services provide a much more attractive alternative for this clientele, despite the fees they charge. They do so because they represent an institutional solution to the ‘imperfect information’ problem in health care. Through simulations based on data from Cameroon, we demonstrate that if fee-charging NGOs replace the highly subsidised but poorly managed facilities operated by African governments the poor would be better off. Those NGOs that are decentralised in their financial and personnel management are most effective. The politics of making the recommended changes are assessed.     

Planning,Budgeting, and Health Care Performance in Ukraine

Abstract

The Government of Ukraine has not pursued health care reforms now commonplace in the rest of Europe and Central/Eastern Europe that rely less upon centralized, state delivery of services and more on decentralized operational responsibilities and competition for services that increase patient choice. The Ukrainian health sector suffers from personnel overspecialization and facility overcapacity, resulting in high-cost, low productivity services. Budget funds are unavailable for operations and maintenance resulting in poor quality services. The state provides health care as a constitutionally-protected monopoly, relying on the traditional command and control model which ignores cost/quality competition options and responsibilities to patients. Overall, the system which produces these results is over-centralized, requiring achievement of physical service norms without providing sufficient funds. The centralized system does not monitor or evaluate services beyond narrow financial accountability and control requirements. The health care system is paradoxically over-centralized but unable to regulate or control local health care official decisions to ensure compliance with national standards. Needed are reforms in the health care policy and operational areas to produce the supply of services needed for national economic recovery. In the short-term, the budgetary framework can be improved as an operational/management guide through development of comparative information on results. Most of this information can be based on the economic classification consistent with the chart of accounts. Funding stability can be increased to improve expenditure control by implementing a new fiscal transfer formula that provides discretion (i.e., block grants) and performance criteria (i.e., outcome measures). In the medium-term, building on the technical foundation of physical norms and statistical reporting, the health care budgeting and financial management system should shift emphasis to: program planning, policy and management analysis, and public communications. The results of these reforms should lead to decentralized health care operations, service analysis, and delivery responsibilities. At the same time, the reforms should lead to proper centralization of responsibilities for strategic policy decisions, safety regulation, national standards, and program evaluation.     

Reforming united states' health care system

The US health care system, characterized by high costs and limited health benefits coverage, is constantly undergoing reform. This paper presents a brief overview of the US health care system and its current reform: the use of managed care and medical savings account plans; reducing Medicare and Medicaid spending; and the regulation of managed care system.