Análisis químico del suelo

“The general egalitarian principle in health care has been defined as receiving treatment according to need and paying according to ability to pay. […] The current emphasis on health care reform has potential to lead increasingly to the provision of health services and treatment according to willingness to pay, a trend which undermines the principle as far as both paying according to the ability to pay and provision of care according to need are concerned.” (Koivusalo/Ollila 1996)

Health care reforms have an air of being something innovative and purposeful. They are designed to perpetuate the provision of public and private health services by redefining the framework for the societal and structural changes of the future – and for the market. [Stein 2006] Policymakers have tried to find concepts, which enable the combination of social equity and entrepreneurial efficiency. Since cost control has come into the focus of most governments, they shift their focus on setting standards and monitoring and evaluating outputs. The idea is to organise the health care system more effectively and efficiently while at the same time improving the quality of and guaranteeing accessibility to services. [Saltman 2002] So for the past two decades, the mature health systems of

this world have been practicing themselves in continuous health care reforms, sometimes implementing diametrically opposed approaches, but always trying to reach the same goals: cost containment and introduction of ‘more market and competition’. [Eckel 2001, Huber 2001, Glouberman/Mintzberg 2001, Plesk/Greenhalgh 2001, Crinson 2009, Amelung et al. 2009] A regular update and documentation of these reform efforts can be found in the ‘Health Systems in Transition (HiT)’ series of the WHO Regional Office for Europe.6

2.3.1 Reforms and Regulations

There has already been extensive mention of ‘regulation’ throughout this chapter. It is an intrinsically political function, which gives the state, government or “regulator” the instrument with which to steer and control the actors in the system. Whether it is the ‘invisible hand’ of Adam Smith or a more active proponent of the social welfare states determines the form, impact and range of its regulations. Regulations form a permanent or at least long term framework, whereas reforms are temporary interventions, albeit with long term effects. [Noweski 2008]

2.3.2 Levers for Reform

There are three major concerns common to all reforms: the introduction of user charges, the issue of health insurance and decentralisation [Koivusalo/Ollila 1996, Güntert 2008]:

• The user charges in government health facilities have been promoted as a way to mobilise revenues, promote efficiency, foster equity, increase decentralisation and sustainability, and foster private sector development.

• Health insurance is seen both as a problem and a solution in health care reforms. […] According to the egalitarian aims in health care, insurance cost-sharing should be based on the ability to pay, without changes in benefits.

• Decentralisation can be defined as the transfer of authority in public planning, management and decision making from the national to the regional and community levels. Different degrees according to the actual transfer of power are distinguished: deconcentration, devolution, delegation and privatisation. Although it is appreciable to move the decision making process nearer to where the people concerned are, this concept also poses many problems in execution. The subordinate levels may lack the managerial skills and the financial and human resources to administer the new responsibilities. Furthermore, it adds yet another layer to public administration and hence increases instead of decreases costs.

6

Porter and Teisberg (2006) argue on similar lines when they identify three “broad areas” of health care: the cost and access to health insurance, the coverage of health insurance versus individual contributions and the organisation of health care delivery itself. Along these lines important decisions have to be made about the extent to which resources are distributed and which principles and aims are applied to distribute these finite resources.

Figure 2.6. The ‘Bermuda Triangle’ of health care provision.

Source: Güntert (2008).

Further aspects of health care reform are connected with the cooperation within and between organisations and professions, the establishment of networks and the introduction of management tools, such as quality assurance, performance measurement or process and information management. [Halvorson 2007, Amelung et al. 2009]

2.3.3 “Culture Trumps Strategy” - Making a Change

The major obstacle to be overcome in implementing any kind of change is “culture”. Halvorson (2007) attests the culture(s) within a health care system to be uniquely immune to any kind of change. “Health care is an ultimate bastion of the ‘not invented here’ approach to idea rejection.” [Halvorson 2007, p. 87] Likewise, managers and agents in the health institutions have learnt to “sit out” any reform and reorganisation issues, knowing that these efforts will pass and they can continue with business as usual after the storm has passed. [Glouberman/Mintzberg 2001] Unlike other areas of the

Optimise total benefit through prioritisation

Rationing

Limit services based on financing restraints

Rationalisation

Rational allocation

Improve resource utilisation through better management

economy, where the evaluation of good and best practices and the sharing of experiences is inherent in the business models, every unit in every hospital or doctor’s office has its own set of rules and procedures, cultures to be well aware of. The concepts of systematic process analysis and improvement, of quality management and transparency are whole new sciences for health care systems and their actors, in which none of them are trained. [Halvorson 2007] The constant reform efforts of the past decades may have introduced these instruments into the systems, but they are far from having changed the attitudes of those supposedly implementing them. It may be time to stop reforming and start acting since “[…] systems and institutions are like people in that they function best under steady care, not intermittent cure. The problem is not how to intervene across the great horizontal divide, but how to dissolve it into a cooperative network.” [Glouberman/Mintzberg 2001, p. 63]

Table 2.2. Options for designing future health care systems.

Source: Adapted from Güntert (2008).

• Consistent rationalisation to avoid rationing and to reach the best possible cost/benefit ratio.

• Securing a good basic health care system for everyone by governmental regulation. • Use a combination of different systems to finance the health care system.

• Improve the knowledge base for rational decision making on all levels. • Promote innovations which also lead to rationalisation.

• Improve health promotion on all levels to secure better health outcomes and a more equitable health care.

• Improve integration of the different providers and actors in the system by using information technology, incentivise cooperation and promote integrated care.

• Clear regulations for quality standards on all levels to increase transparency and enhance outcomes measurement.