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Globalization and Health Care Systems Reform Bernardo Ramirez MD, MBA UCF Health Management and Informatics April 2013 Globalization and Health Care Systems Global Health Care •Global Health Care Management Experience Management •Study tour 2005 (US, Canada, Experience Mexico,UK and Australia) •All countries in the Americas •Partnerships Europe, CEE and NIS (Hospitals, Managed Care, Health Systems, Health Reform, Education and training on health services management [human resources development, institutional strengthening]) •Managerial and Health Services Research Perspectives •Globalization impact in health and health care services and management •Health systems reform strategies with issues like competitiveness, state regulations, insurance companies, public private partnerships and patient empowerment •Quality, safety and performance improvement •Value and impact of heath care. Chronic Care Physician Views of the Health System, 2009 and 2012: “System Works Well, Only Minor Changes Needed” Percent Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care 3 Physician Satisfaction with Practicing Medicine Percent Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care 4 Examples of global issues in healthcare include: Outsourcing of medical services (e.g. medical transcribing, radiology, billing support – similar to other businesses) Acquisitions and consolidations in the pharmaceutical industry Movement of health professional labor across national borders Medical tourism; competition for international patients Immigration and global workforce Global health – pandemics (e.g. HIV/AIDS, Avian flu, SARS) Comparative Health Systems and Health Reforms HEALTH AS A SYSTEM STRUCTURE PROCESS OUTPUTS OUTCOMES PRODUCTIVITY EFFICIENCY RESOURCES HEALTH SERVICES POPULAT ION UTILIZAT ION HEALTH STATUS EFFECTIVENESS Adapted from Donabedian A. (2005) Evaluating the Quality of Medical Care. Milbank Quarterly Vol 83-No4, Reprinted from Vol44No3, 1966. And From Bradbury R. (1992) Health Systems Analysis and Hospital Quality Improvement. ISQUA,9 th International Conference Mexico. Health Services Elements Population Access/utilization (Education, Health Promotion, Options for Care, Legal Aspects, Geographical and Cultural Barriers) Epidemiology (Transition, Mortality, Morbidity, Population, Life Expectancy) Life Styles and behaviors (Prevention and chronic health, Patient & Family Centered) Health Services Elements Resources Physical Resources, (hospitals, clinics, privatepublic, Ambulatory services) Equipment/Technology, Medicines Human resources (Education, health manpower, Incentives, training, continuing education, Physicians, nurses, technicians and emerging professions) Financial Resources (Resource allocation, budgets, financial schemes, reimbursement, insurance mechanisms) Health Services Elements Health Services Primary/Secondary health care. Systems. Management Information Systems Clinical Standards and Protocols. Safety Issues. Quality Assurance and Quality Improvement Legal aspects (malpractice) Incentives, Performance management. Cost or services Efficiency, clinical & Management efficiency Effectiveness, Health Impact and outcomes Types of Health Care Services Traditional, spiritual, empirical Charitable and altruistic organizations Entrepreneurial Private practice Welfare-oriented, social insurance Government and centrally planned Prepaid voluntary insurance Owned by industry for their workers Origins of Health Care Systems England. Chadwick report on laboring conditions. Boards of Public Health (1850). Mandatory Insurance for workers (1911) Welfare State Beveridge Report (1942), NHS (1948) Germany. Bismarck, Mandatory insurance for injury and illness (1883) Central Planning Concept: Semashko. (1923) Mixed Systems from tax-free health care in Saudi Arabia to combination of public-private Ward in a London Hospital 2003 Infant Mortality and Total Heath Spending (% GDP) Total Health Spending (% GDP) & Body Mas Index THE HEALTH TRIANGLE ACCESS EQUITY COST QUALITY & PERFORMANCE MANAGEMENT Adapted from Cost, access, quality triangle. Harvard Medical International, 2002 Retrieved from the Internet December 20, 2006 http://www.hmiworld.org/hmi/issues/Sept_Oct_2002/features_health_systems.html Average Health Care Spending per Capita, 1980–2010 16 Adjusted for Differences in Cost of Living Dollars ($US) * 2009 Source: OECD Health Data 2012. THE COMMONWEALTH FUND Health Care Spending as a Percentage of GDP, 1980–2010 17 Percent * 2009 GDP refers to gross domestic product. Source: OECD Health Data 2012. THE COMMONWEALTH FUND Health Care Spending per Capita by Source of Funding, 2010 18 Adjusted for Differences in Cost of Living Dollars ($US) 8,233 5,269 4,463 * 2009. Source: OECD Health Data 2012. 4,445 4,338 3,974 3,758 3,670 3,433 3,035 3,022 THE COMMONWEALTH FUND Pharmaceutical Spending per Capita, 2010 19 Adjusted for Differences in Cost of Living Dollars ($US) * 2009. ** 2008. Source: OECD Health Data 2012. THE COMMONWEALTH FUND Relation of Health with Physicians Will problems be solved in developing countries if there were more physicians? More and other health professionals? Different Health Personnel Ratios? How about training, incentives, etc? More hospitals and health centers? More technology? Number of Practicing Physicians per 1,000 Population, 2010 * 2009. Source: OECD Health Data 2012. 21 THE COMMONWEALTH FUND Average Annual Number of Physician Visits per Capita, 2010 * 2009. ** 2008. Source: OECD Health Data 2012. 22 THE COMMONWEALTH FUND Doctors’ Perception of Patient Access Barriers Percent reporting their patients OFTEN have: AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US Difficulty paying out-of-pocket costs 25 26 29 21 42 26 4 6 16 13 59 Difficulty getting diagnostic tests 16 38 41 27 7 59 10 15 3 14 23 Long waits to see a specialist 60 73 59 68 21 75 60 49 10 28 28 Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care 23 Practice Has Arrangement for Patients’ After-Hours Care to See Doctor or Nurse Percent * In Norway, respondents were asked whether there practice has arrangements or if there are regional arrangements. Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care 24 Practice Uses Nurse Case Managers or Navigators for Patients with Serious Chronic Conditions Percent Note: Question asked differently in France. Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care 25 Primary Care Doctors’ Receipt of Information from Specialists Percent said after their patient visits a specialist they always receive: AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US Report with all relevant health information 32 26 51 13 13 41 26 12 59 36 19 Information about changes to patient’s drugs or care plan 30 24 47 12 5 44 22 13 44 41 16 Information that is timely and available when needed 13 11 26 4 1 15 4 8 27 18 11 Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care 26 Health Sector Reforms Around The World Balance the Iron Triangle (Access-Quality-Cost) Reorient MOH (make them smaller or more functional, performance, accountability, modernization, separate provision from financing, competition, Chronic-Acute Care) Institute user charges-AccountabilityInstitute or expand health insurance schemes Decentralize-Empowerment Third party Contracts with private/public providers Sustainability: The capacity of health services to function with efficiency, including the financial, environment and social interaction that guaranties an effective service now and in the future, with a minimum of external intervention and without limiting the capacity of future generations to fulfill their needs. Adapted from Gallopin Gilberto. A systems approach to sustainability and sustainable development. Sustainable Development and Human settlements Division. ECLAC/Government of the Netherlands. Project “Sustainable Assessment in Latin America and the Caribbean” Santiago de Chile, March 2003 Areas and Dimensions Sustainability of Processes Sustainability of Organizations The dimensions of sustainability are grouped in five areas: The environment Socio-Cultural Institutional Capacity Development The Financial Dimension The Political Dimension