Welche Gesundheitssysteme sind besonders innovative und belegen Spitzenplätze im internationalen Vergleich?

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1 Welche Gesundheitssysteme sind besonders innovative und belegen Spitzenplätze im internationalen Vergleich? Prof. Dr. Claus Wendt Lehrstuhl für Soziologie der Gesundheit und des Gesundheitssystems 12. Schweizerischer Kongress für Gesundheitsökonomie und Gesundheitswissenschaften & ZUKUNFTSFORUM GESUNDHEIT Freitag 23. Oktober Uhr Inselspital, Universitätsspital Bern Zentrum für Sozialwissenschaftliche Forschung -

2 Übersicht Teil 1: Rankings von Gesundheitssystemen Teil 2: Gesundheitssystemvergleich: Institutionen, Akteure & Innovation Teil 3: Gesundheitssystemvergleich: Aufbau & Wirkungen Teil 4: Zufriedenheit, Zugangschancen, Gesundheit & gesundheitliche Ungleichheit

3 Teil 1: Rankings von Gesundheitssystemen: WHO Ranking France 2 Italy 3 San Marino 4 Andorra 5 Malta 6 Singapore 7 Spain 8 Oman 9 Austria 10 Japan 11 Norway 12 Portugal 13 Monaco 14 Greece 15 Iceland 16 Luxembourg 17 Netherlands 18 United Kingdom 19 Ireland 20 Switzerland 21 Belgium 22 Colombia 23 Sweden 24 Cyprus 25 Germany 26 Saudi Arabia 27 United Arab Emirates 28 Israel 29 Morocco 30 Canada 31 Finland 32 Australia 33 Chile 34 Denmark 35 Dominica 36 Costa Rica 37 United States 38 Slovenia 39 Cuba 40 Brunei 41 New Zealand 42 Bahrain 43 Croatia 44 Qatar 45 Kuwait 46 Barbados 47 Thailand 48 Czech Republic 49 Malaysia 50 Poland 51 Dominican Republic 52 Tunisia 53 Jamaica 54 Venezuela 55 Albania 56 Seychelles 57 Paraguay 58 South Korea 59 Senegal 60 Philippines

4 WHO Ranking, Indikatoren The ranking is based on an index of five dimensions: Health (50%) : disability-adjusted life expectancy Overall or average : 25% Distribution or equality : 25% Responsiveness (25%) : speed of service, protection of privacy, and quality of amenities Overall or average : 12.5% Distribution or equality : 12.5% Fair financial contribution : 25%

5 Euro Health Consumer Index 2014

6 Euro Health Consumer Index, Beispiel für Indikatoren

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11 Übersicht

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13 Akteure, Institutionen und Reformen

14 Teil 2: A conceptual framework that combines financing, service provision, and regulation Financing agencies Regulation Service providers Financing Service provision (Potential) beneficiaries Goals / values / perceptions

15 Teil 2: Klassifikation von Gesundheitssystemen Healthcare System Type Regulation Financing Provision 1 Ideal-type: State Healthcare System State State State 2 State-based mixed-type State State Societal 3 State-based mixed-type State State Private 4 State-based mixed-type State Societal State 5 State-based mixed-type State Private State 6 State-based mixed-type Societal State State 7 State-based mixed-type Private State State 8 Societal-based mixed-type State Societal Societal 9 Societal-based mixed-type Societal State Societal 10 Societal-based mixed-type Societal Societal State 11 Ideal-type: Social Insurance System Societal Societal Societal 12 Societal-based mixed-type Societal Societal Private 13 Societal-based mixed-type Societal Private Societal 14 Societal-based mixed-type Private Societal Societal 15 Private-based mixed-type State Private Private 16 Private-based mixed-type Private State Private 17 Private-based mixed-type Private Private State 18 Private-based mixed-type Societal Private Private 19 Private-based mixed-type Private Societal Private 20 Private-based mixed-type Private Private Societal 21 Ideal-type: Private Healthcare System Private Private Private 22 Pure Mixed-type State Private Societal 23 Pure Mixed-type State Societal Private 24 Pure Mixed-type Private State Societal 25 Pure Mixed-type Private Societal State 26 Pure Mixed-type Societal State Private 27 Pure Mixed-type Societal Private State

16 Teil 2: Klassifikation von Gesundheitssystemen Healthcare System Type Regulation Financing Provision 1 Ideal-type: State Healthcare System State State State 2 State-based mixed-type State State Societal 3 State-based mixed-type State State Private 4 State-based mixed-type State Societal State 5 State-based mixed-type State Private State 6 State-based mixed-type Societal State State 7 State-based mixed-type Private State State 8 Societal-based mixed-type State Societal Societal 9 Societal-based mixed-type Societal State Societal 10 Societal-based mixed-type Societal Societal State 11 Ideal-type: Social Insurance System Societal Societal Societal 12 Societal-based mixed-type Societal Societal Private 13 Societal-based mixed-type Societal Private Societal 14 Societal-based mixed-type Private Societal Societal 15 Private-based mixed-type State Private Private 16 Private-based mixed-type Private State Private 17 Private-based mixed-type Private Private State 18 Private-based mixed-type Societal Private Private 19 Private-based mixed-type Private Societal Private 20 Private-based mixed-type Private Private Societal 21 Ideal-type: Private Healthcare System Private Private Private 22 Pure Mixed-type State Private Societal 23 Pure Mixed-type State Societal Private 24 Pure Mixed-type Private State Societal 25 Pure Mixed-type Private Societal State 26 Pure Mixed-type Societal State Private 27 Pure Mixed-type Societal Private State

17 Teil 2: Klassifikation von Gesundheitssystemen Healthcare System Type Regulation Financing Provision 1 Ideal-type: State Healthcare System State State State 2 State-based mixed-type State State Societal 3 State-based mixed-type State State Private 4 State-based mixed-type State Societal State 5 State-based mixed-type State Private State 6 State-based mixed-type Societal State State 7 State-based mixed-type Private State State 8 Societal-based mixed-type State Societal Societal 9 Societal-based mixed-type Societal State Societal 10 Societal-based mixed-type Societal Societal State 11 Ideal-type: Social Insurance System Societal Societal Societal 12 Societal-based mixed-type (Germany, Austria) Societal Societal Private 13 Societal-based mixed-type Societal Private Societal 14 Societal-based mixed-type Private Societal Societal 15 Private-based mixed-type State Private Private 16 Private-based mixed-type Private State Private 17 Private-based mixed-type Private Private State 18 Private-based mixed-type Societal Private Private 19 Private-based mixed-type Private Societal Private 20 Private-based mixed-type Private Private Societal 21 Ideal-type: Private Healthcare System Private Private Private 22 Pure Mixed-type State Private Societal 23 Pure Mixed-type State Societal Private 24 Pure Mixed-type Private State Societal 25 Pure Mixed-type Private Societal State 26 Pure Mixed-type Societal State Private 27 Pure Mixed-type Societal Private State

18 Teil 2: Klassifikation von Gesundheitssystemen Healthcare System Type Regulation Financing Provision 1 Ideal-type: State Healthcare System State State State 2 State-based mixed-type State State Societal 3 State-based mixed-type State State Private 4 State-based mixed-type (CEE) State Societal State 5 State-based mixed-type State Private State 6 State-based mixed-type Societal State State 7 State-based mixed-type Private State State 8 Societal-based mixed-type State Societal Societal 9 Societal-based mixed-type Societal State Societal 10 Societal-based mixed-type Societal Societal State 11 Ideal-type: Social Insurance System Societal Societal Societal 12 Societal-based mixed-type Societal Societal Private 13 Societal-based mixed-type Societal Private Societal 14 Societal-based mixed-type Private Societal Societal 15 Private-based mixed-type State Private Private 16 Private-based mixed-type Private State Private 17 Private-based mixed-type Private Private State 18 Private-based mixed-type Societal Private Private 19 Private-based mixed-type Private Societal Private 20 Private-based mixed-type Private Private Societal 21 Ideal-type: Private Healthcare System Private Private Private 22 Pure Mixed-type State Private Societal 23 Pure Mixed-type State Societal Private 24 Pure Mixed-type Private State Societal 25 Pure Mixed-type Private Societal State 26 Pure Mixed-type Societal State Private 27 Pure Mixed-type Societal Private State

19 Teil 2: Klassifikation von Gesundheitssystemen Healthcare System Type Regulation Financing Provision 1 Ideal-type: State Healthcare System State State State 2 State-based mixed-type State State Societal 3 State-based mixed-type State State Private 4 State-based mixed-type (Denmark, pre-1970) State Societal State 5 State-based mixed-type State Private State 6 State-based mixed-type Societal State State 7 State-based mixed-type Private State State 8 Societal-based mixed-type State Societal Societal 9 Societal-based mixed-type Societal State Societal 10 Societal-based mixed-type Societal Societal State 11 Ideal-type: Social Insurance System Societal Societal Societal 12 Societal-based mixed-type Societal Societal Private 13 Societal-based mixed-type Societal Private Societal 14 Societal-based mixed-type Private Societal Societal 15 Private-based mixed-type State Private Private 16 Private-based mixed-type Private State Private 17 Private-based mixed-type Private Private State 18 Private-based mixed-type Societal Private Private 19 Private-based mixed-type Private Societal Private 20 Private-based mixed-type Private Private Societal 21 Ideal-type: Private Healthcare System Private Private Private 22 Pure Mixed-type State Private Societal 23 Pure Mixed-type State Societal Private 24 Pure Mixed-type Private State Societal 25 Pure Mixed-type Private Societal State 26 Pure Mixed-type Societal State Private 27 Pure Mixed-type Societal Private State

20 Teil 2: Klassifikation von Gesundheitssystemen Healthcare System Type Regulation Financing Provision 1 Ideal-type: State Healthcare System (DK, post-1970) State State State 2 State-based mixed-type State State Societal 3 State-based mixed-type State State Private 4 State-based mixed-type State Societal State 5 State-based mixed-type State Private State 6 State-based mixed-type Societal State State 7 State-based mixed-type Private State State 8 Societal-based mixed-type State Societal Societal 9 Societal-based mixed-type Societal State Societal 10 Societal-based mixed-type Societal Societal State 11 Ideal-type: Social Insurance System Societal Societal Societal 12 Societal-based mixed-type Societal Societal Private 13 Societal-based mixed-type Societal Private Societal 14 Societal-based mixed-type Private Societal Societal 15 Private-based mixed-type State Private Private 16 Private-based mixed-type Private State Private 17 Private-based mixed-type Private Private State 18 Private-based mixed-type Societal Private Private 19 Private-based mixed-type Private Societal Private 20 Private-based mixed-type Private Private Societal 21 Ideal-type: Private Healthcare System Private Private Private 22 Pure Mixed-type State Private Societal 23 Pure Mixed-type State Societal Private 24 Pure Mixed-type Private State Societal 25 Pure Mixed-type Private Societal State 26 Pure Mixed-type Societal State Private 27 Pure Mixed-type Societal Private State

21 Teil 2: Wandel von Gesundheitssystemen 1. Systemwechsel: Veränderungen der zentralen Charakteristika von Gesundheitssystemen, so dass sich das Gesundheitssystem im Ganzen neu ausrichtet. 2. Änderungen in Bezug auf eine der drei Dimensionen: Die Regulierung, Finanzierung oder Leistungserbringung wird neu ausgerichtet, ohne dass sich die anderen beiden Dimensionen verändern. 3. Veränderungen innerhalb einer Dimension: Es handelt sich um Niveauverschiebungen, die innerhalb einer oder mehrerer Dimensionen stattfinden, ohne dass sich die jeweilige Grundausrichtung (staatlich, privat, gesellschaftlich) verändert.

22 Teil 2: Welches Gesundheitssystem ist besonders innovativ? 1. Es gibt Beispiele für Innovationsfreudigkeit in unterschiedlichen Systemtypen. 1. Dänemark (hohe Bedeutung der lokalen Ebene) 2. Großbritannien (internal market + mehr Reformen, als der zentralstaatliche Einfluss verringert wurde) 3. Deutschland (höhere Reformdichte nach Einführung des Wettbewerbs) 4. Mittel- und Osteuropa (zentralstaatliche Ebene ist nach wie vor sehr einflussreich) 2. Wenn die lokale und regionale Ebene an Bedeutung gewinnt, nehmen Reformen zu. 3. Werden systemfremde Elemente (z.b. Wettbewerb in einem staatlichen System) eingeführt, steigt ebenfalls die Abfolge von Reformen. 4. Private Gesundheitssysteme sind nicht reformfreudiger als staatliche

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25 Daten Makro Indikatoren Expenditure, Financing, Employment: OECD Health Data Institutional indicator: Case studies (European Observatory); Comparative studies 15 Europäische Länder

26 Indikatoren für die vergleichende Analyse von Gesundheitssystemen Dimension Total Health Expenditure (THE) Public-private mix of health financing Privatization of risk Healthcare provision Remuneration of doctors Patients access to service providers Indicator THE per head of the population in USD (PPP) Public funding in % of THE Private out-ofpocket funding in % of THE Indices of healthcare providers Remuneration of GPs on the basis of feefor-service, per capita, cost per case, or a salary Access-Regulation Index Description Average level of monetary inputs invested in a person s health Indicator of the degree of public responsibility to guarantee access to healthcare Share of funding that is directly covered by the individual; barrier to the access of healthcare, particularly for low-income groups Indicators for the level of healthcare providers. The indices are constructed by using data on specialists, nurses, general practitioners, and pharmacists. The method of remuneration indicates whether doctors have an incentive to provide high-volume healthcare. It is covered regardless as to whether patients have free access to GPs and whether access to specialists requires a referral, additional copayment, or is free.

27 Daten für die Konstruktion von Gesundheitssystemtypen Health funding and private payment THE a) per capita, USD PHE b) in % of THE Private OOP c) in % of THE In-patient index Healthcare provider indices d) Out-patient index Institutional indicators Remuneration of GPs e) Austria Belgium Denmark Finland France Germany Great Britain Greece Ireland Italy Luxembourg Netherlands Portugal Spain Sweden Accessregulation index f) a) THE: total health expenditure; b) PHE: public health expenditure; c) OOP: out-of-pocket payments; d) Construction of indices (see table ); e) Coding for remuneration: fee-for-service = 0; capitation = 1; salary = 2; f) Coding for index construction (see table 3.3).

28 Hierarchical cluster analysis: Dendrogram using average linkage

29 Hierarchical cluster analysis: Dendrogram using average linkage

30 Teil3: Beschreibung der Cluster THE in USD per capita Public funding in % of THE Private out-ofpocket payment in % of THE Index inpatient care Index outpatient care Remuneration of GPs Accessregulation index Cluster 1 AT, BE, DE, FR, LU High level of THE (at average 2,702 USD per head) High share of public funding (79% of THE) Medium share of out-of-pocket payment (13% of THE) Medium inpatient index (105) High outpatient index (133) Fee-for-service Low regulation Cluster 2 DK, GB, IE, IT, NL, SE Medium level of THE (2,325 USD) High share of public funding (77% of THE) Medium out-ofpocket payment (15% of THE) Medium inpatient index (104) Low outpatient index (74) Capitation (except SE: salary) Medium to strong regulation Cluster 3 ES, FI, PT Low level of THE (1,706 USD) Medium public funding (72% of THE) High out-ofpocket payment (23% of THE) Low inpatient index (80) Medium outpatient index (107) Salary Strong regulation

31 Teil 3: Drei Typen von Gesundheitssystemen 1. A health service provision oriented type (Austria, Belgium, France, Germany, and Luxembourg) that is characterized by a high level of service providers and free access for patients to medical doctors; 2. A universal coverage controlled access type (Denmark, Great Britain, Ireland, Italy, the Netherlands, and Sweden) where healthcare provision has the status of a social citizenship right, and equal access to healthcare is of higher importance than direct access and freedom of choice; 3. A low budget restricted access type (Portugal, Spain, and Finland) where financial resources for healthcare are limited and patients access to healthcare is restricted since private out-of-pocket payments are high and patients have to sign on a general practitioner s list for a longer period of time.

33 Teil 4: Zufriedenheit der Bevölkerung im internationalen Vergleich Können institutionelle Bedingungen identifiziert werden, die sich auf die Wahrnehmung und Bewertung von Gesundheitssystemen auswirken? Sind die Unterschiede zwischen sozialen Gruppen im Ländervergleich ähnlich oder hängen sie vom jeweiligen institutionellen Kontext ab? Wendt, Claus, Monika Mischke, Michaela Pfeifer (2011): Welfare States and Public Opinion: Perceptions of Healthcare Systems, Family Policy and Benefits for the Unemployed and Poor in Europe, U.K. and Northampton, MA, U.S.A.: Edward Elgar Publishing Wendt, C., J. Kohl, M. Mischke, M. Pfeifer (2010): How Do Europeans Perceive Their Healthcare System? Patterns of Satisfaction and Preference for State Involvement in the Field of Healthcare. European Sociological Review, 26, 2,

34 Institutionelle Einflussfaktoren auf Einstellungen zur Rolle des Staates (Extensität) und auf die Zufriedenheit Extensität Zufriedenheit Pearson s R N Pearson s R N Gesamtausgaben (THE) in US$ pro Kopf, PPP THE in % des GDP Öffentl. Ausgaben in US$ pro Kopf, PPP * 14 Öffent. Ausgaben in % der THE Private Zuzahlungen in % der THE Allgemeinärzte (GPs) je 1,000 Einwohner ** 14 Index Zugangsregulierung

35 Multivariate Analysen (Results for pooled OLS Regressions for extensive role of the state and satisfaction with healthcare ) Ohne Makro- Indikatoren Extensität Mit Makro- Indikatoren Ohne Makro- Indikatoren Zufriedenheit Mit Makro- Indikatoren Subj. gute Gesundheit (schlecht) * ** Alter (65+) Jahre * * Jahre *** *** Subj. hohes Einkommen (niedrig) * *** *** *** Soziale Klasse/ESEC (ESeC 4 und 5) Esec * * Esec Esec Studierende Zeit Ärzte, positiv bewertet *** ** *** *** PHE in US$ pro Kopf (PPP) Private Zuzahlungen in % THE * GPs je 1,000 Einwohner *** Index der Zugangsregulierung N adj. R

36 Teil 4: Ungleichheiten der Inanspruchnahme von Gesundheitsleistungen Führt eine stärkere Kontrolle des Zugangs im Ländervergleich zu einer geringeren Nutzung von Gesundheitsleistungen? Reduziert eine stärkere Regulierung des Zugangs Ungleichheiten bei der Leistungsinanspruchnahme zwischen Gruppen mit unterschiedlichem Einkommen bzw. Bildungsniveau? Reibling, N. and Wendt, C. (2012): Gatekeeping and Provider Choice in OECD Healthcare Systems. Special Issue, edited by E. Annandale and E. Kuhlmann, Current Sociology, 60, 4, Reibling, N. and Wendt, C. (2011): Regulating Patients Access to Healthcare Services. International Journal of Public and Private Healthcare Management and Economics, 1, 2, 1-16

37 Gatekeeping - Index Land GP Registrierung Regionale Begrenzung GPs: pro Kopf Honorierung Zugang zu Facharzt Zugang ambulante fachärztl. Versorg. im KH Index Regulierung (LRI) Frankreich Frei Frei 0 0 Griechenland Frei Frei 0 0 Schweiz Frei Frei 0 0 Belgien zus. Zuzahl. zus. Zuzahl Deutschland Frei Überweisung Österreich zus. Zuzahl. zus. Zuzahl Schweden zus. Zuzahl. zus. Zuzahl Niederlande Überweisung Überweisung Spanien Überweisung Überweisung Dänemark Überweisung Überweisung 7 10 Italien Überweisung Überweisung 7 10 LRI (0-10)

38 Arztbesuche in Abhängigkeit von chronischen Erkrankungen

39 Unterschiede der Leistungsinanspruchnahme (Facharzt) zwischen Bildungsgruppen

40 Health Inequalities in European Welfare States (HiNews)

41 Prof. Dr. Claus Wendt