Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
보건정치경제 (Political Economy of Health Systems and Policies) March 2012 Prof. Soonman Kwon, Ph.D. 1 Soonman KWON Ph.D. (Health Economics and Policy), Wharton School, University of Pennsylvania, 1993 Academic Appointments School of Public Policy, Univ. of Southern California, 1993-96 School of Public Health, Seoul National Univ., 1997-present Visiting Professor Germany: Univ. of Duisburg, Dept of Economics (summer 1999), Trier (summer 2001, DAAD scholar), Bremen (summer 2003) Harvard School of Public Health, Dept of International Health (Takemi Fellow and Fulbright Scholar: January-August 2002) London School of Economics and Political Science, Dept of Social Policy (Sep 2002 - Jan 2003) Hosei University, Institute of Aging, Japan (January 2004) University of Toronto, Dept of Political Science (Jan-Aug 2006) 2 Teaching - 보건정치경제 (Political Economy of Health Systems and Policies) - 보건재정정책 및 관리 (Health Care Financial Policy and Management) - 비교보건정책 (Comparative Health System and Policy) - 노령화와 장기요양정책 (Aging and Long-term Care Policy) 보건정치경제 연구실: www.heamang.net 국내 학회 활동 - 한국노년학회 부회장 역임 - 한국보건경제학회 부회장 (현재) - 현재 보건행정학회 학술이사, 사회보장학회 기획이사 3 최근 연구 용역 (연구책임자) - BK (Brain Korea) 노인보건정책연구팀 연구책임자 - Impact of economic recession on health in Asia (ADB/WHO) - Framework for assessing health system in developing countries (GTZ) 건강보험 보장성 강화 전략 (보건복지부) 건강보험 보장성 우선순위 원칙 및 적용방안 (건강보험공단) 암보장성 강화정책의 효과 평가 (NECA) 한국 의료보장 선진화 방안 (기획재정부) 장기요양 급여비용 결정구조 개선 방안 (건강보험공단) 지속가능한 장기요양보험 재정추계 (보건복지부) 장기요양보험 도입의 경제성 평가 (보건복지부) 국내외 제네릭 약가 비교 (보건복지부) DUR 시범사업평가 (건강보험심사평가원) 보건의료 국제개발사업 수행체계 및 프로그램 개발 (보건복지부) 남북 보건의료협력사업 경제성 평가 (보건복지부) 공공의료기관 경영효율화 방안 (국가경쟁력강화위원회) 건강형평성 성과 지표 개발 (보건복지부) 4 국제학술지 편집위원 (Editorial Board Members) Social Science and Medicine Health Economics Policy and Law Health Systems in Transition (HiT) BMC Health Services Research Ageing Research Review 국제기구 위원회 위원 (Committee Members): - WHO Alliance for Health Policy and Systems - GAVI (Global Alliance for Vaccines and Immunization) 국제기구 Consultant Bhutan (WHO), Cambodia (WHO, GTZ), China (ADB, WHO), Cuba (WHO), Fiji (WHO), Indonesia (WHO), Iran (WHO), Kenya (GIZ), Lao PDR (WHO, World Bank), Malaysia (WHO), Maldives (WHO), Mongolia (WHO, ADB, World Bank), Myanmar (WHO), Pakistan (GTZ), Philippines (GTZ, EU), Uganda (GTZ), Vietnam (WHO, World Bank) 5 I. Health, Health Policy, and Health System Health: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO) -> basic need of human being - > Necessary to fulfill other (political, economic) needs Public Policy (Klein and Marmor, 2006) What governments do and neglect (or decide not) to do About politics, resolving conflicts about resources, rights and morals - Authoritative allocation of values within society (efficiency vs. equity; government vs. market; individual vs. social responsibility) 6 Perspectives on Policy (or policy-making) - Puzzling about ways of tacking social problems: rational policy analysis, finding out the optimal solution, economic evaluation - Bargaining between different interests: process, incremental and evolutionary (Definition, interpretation and framing of problem is political: e.g., financial sustainability of health insurance) Contexts (or determinants) of Public Policy Idea: value, ideology, interpretation, legitimization Interest: distributional consequences, medical profession Institutions: machinery, formal and informal rule of the game, political institutions History: path dependency, legacy, past experience Comparative, policy learning 7 Health Care System: Resources and Organizations (Input, Throughput and Output) 1) Health care financing: different types of financial resource mobilization - public (tax, social insurance) vs. private (private insurance, out-of-pocket payment) - coverage, benefits, resource allocation, payment to providers - health expenditure 2) Health care delivery: health manpower and facilities, pharmaceuticals and technology 3) Health outcomes: health care utilization, life expectancy, mortality, morbidity 8 Example: World Health Report 2000 Health Systems: Improving Performance - Level (achievement) of health outcomes - Distribution of health outcome (horizontal equity or equality) - Responsiveness of health systems - Distribution of responsiveness - Fairness of financial contribution (vertical equity) Level vs. distribution (efficiency vs. equity) 9 M ya n La ma o r PD R Ba I ng nd la ia Si d e s ng h a In por do e Br un P ne ei hili sia D pp ar in us es sa C lam am bo di a N e M pa al l a Sr ys i L ia an ka Pa C h pu a Th ina N ew aila D em G nd .P ui ne eo a pl e' s R Vie Fiji ep t . o Na fK m or e Bh a u Va t an R nu ep at ub u lic To o ng C fK a oo o k rea Is la nd Sa s So m lo Mo oa m on ngo Is lia la nd s Percentage of GDP Health Expenditure as a % of GDP 8 7 6 5 4 3 2 1 0 Government health spending Private health spending 10 Source: WHO, Health Financing Strategy in Asia and the Pacific (2010-2015), 2009 life expectancy at birth 60 70 80 90 Relationship between Health Expenditure and Health Outcomes Singapore Japan Australia New Zealand Republic of Korea Brunei Darussalam Cook Islands China Maldives Thailand Malaysia Viet Nam Jordan Palau Philippines Fiji Tonga Vanuatu Sri Lanka Samoa Mongolia Indonesia Bangladesh India Tuvalu Bhutan Nepal Cambodia Papua New Guinea Lao People's Democratic Republic Niue Micronesia Kiribati Timor-Leste Nauru Marshall Islands 50 Myanmar 0 5 10 Health E as % of GDP Source: WHO, World Health Statistics 2010 15 20 11 90 Japan 80 Singapore Australia New Zealand Republic of Korea Brunei Darussa China Cook Islands Malaysia Viet Nam Sri Lanka Thailand Tonga Fiji Vanuatu Indonesia Samoa Solomon island North Korea Bangladesh India Mongolia Bhutan Nepal Papua New Guin Lao People's D Cambodia Maldives 60 70 Philippines 50 Myanmar 2 Data: WHO, WORLD HEALTH STATISTICS 2009 4 6 health E as % of GDP 8 10 12 % Public in Total Health Expenditure 13 Source: OECD Health Data 2011 H Expenditure and Life Expectancy (2008) Source: OECD Health Data 2011 14 II. Types of Government Intervention and Policy in Health Care 1. Different Mechanisms a. Mandate: final incidence? On the employer: labor market On the consumer: product market b. Financial incentive: depending on the market mechanism Voucher, conditional cash transfer Tax exempt for the premiums for private health insurance c. Direct provision: NHS (National Health Service), public hospitals 15 2. Different Types 1) Entry regulation: license (for minimum standards), certificate, allowing new providers or beds according to government planning or need assessment (e.g., CON (Certificate of Need) in the US) -> could be anti-competitive 2) Price regulation: price regulation of medical care (fee scheduling), price regulation of pharmaceuticals and device 3) Quality regulation: safety and efficacy of drugs/technology, accreditation of providers, medical malpractice (negligence vs. strict liability rule) 16 2. Different types (continued) 4) Provision of information (to mitigate the problems caused by information asymmetry): Evaluation and dissemination of the information on quality a. Evaluation of health care institutions: input – throughput – output ? b. Evaluation of services: e.g., C-section rate, antibiotics use -> how to adjust for patient severity? c. Practice guidelines for providers 17 3. Different sub-sectors a. Physicians: regulation on advertising - informative or deceptive (wasteful competition)? - depends on search, experience, and credence good (characteristic) b. Hospital: requirement on personnel and facility for quality c. Payer: Mandate for the payer to accept all applicants (no cream skimming), mandate community rating or incomebased contribution, uniform or minimum benefit package, d. Pharmaceuticals: reference pricing, advertising on prescription drugs, requirement of substitution of generic for brand-name drugs, technology assessment, listing (positive or negative) for reimbursement 18 III. Determinants and Process of Health Policy Public Policy Institutions, Idea, Interest, History 1. Institutions (제도): Formal and informal rule of game -> Rule of articulating and responding to preferences and social demands (Immergut, 1992) Political Institutions: Constitutional arrangements, organizational structures, conventions of policymaking (Tuohy, 1999) -> affects the course of policy making 19 2. Idea or Value system Value, Idea, Moral, Norm: Assumptive world, interpretation of real world - How health is defined - Who is responsible for health?: individual vs. social - Trust on the government (public sector) Three types - Communitarian: family or social groups -> Germany, Netherlands, Japan - Egalitarian: entitlement or right to health -> Sweden, UK, New Zealand - Individualistic: USA, Australia 20 3. Interest Group Politics in Health Care Separation of Drug Prescribing and Dispensing OTC drug sales in supermarkets Physician opposition to payment system reform Physician, professional dominance Information and knowledge Financial resources Cultural hegemony 21 4. Role of History: Institutional Stickiness, Path dependency or Policy legacies - Future options are foreclosed by past decisions (Klein, 2006) Extent to which particular mode of policy action become institutionalized in a given policy area (Tuohy, 1999) e.g., Similarity between public financing (tax or social insurance) for health care and long-term care - tax financing in Scandinavian countries - social insurance in Germany, Japan, and Korea e.g., Informal rules and culture are difficult to change (e.g., attitude toward drugs in Asia) e.g., Political culture, conservatism in Japan 22 23