Gesundheitssysteme. vergleichende Daten (I)

Transkript

1 Gesundheitssysteme Definitionen, Modelle und vergleichende Daten (I) Reinhard Busse, Prof. Dr. med. MPH FFPH FG Management im Gesundheitswesen, Technische Universität Berlin (WHO Collaborating Centre for Health Systems Research and Management) & European Observatory on Health Systems and Policies

2

3

4 Definition of Health systems people, institutions and resources, arranged together in accordance with established policies, to improve the health of the population p they serve, while responding to people s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health. h European Observatory for Health Systems and Policies (2007). Glossary.

5 WHO World Health Report 2000

6 WHO Framework: strategy bhidw behind World ldhealth hreport 2000 Source: World Health Organization (WHO). (2007) Everybody s business: Strengthening health systems to improve health outcomes. WHO s framework for action. Geneva: WHO Document Production Services.

7 A starting point: 2000 World Health Report First attemptto to rank performance of 191 national health systems Identifies and measures performance of member states on key health system objectives Examines whether each health system is performing as well as it can, given existing resources BasedonMurray & Frank framework (2000)

8 but not everyone agreed

9 Difficulties in deciding what to measure and how to operationalize e it The health of nations MODERN medicine may be good at gauging the health hof patients, but it has proved less successful at taking its own pulse. Assessing the performance of a country s health care system is no easy task, because deciding what to include from doctors to drugs to diet is difficult, and because some chosen criteria, from infant mortality to patient satisfaction, are themselves hard to define. Making comparisons between countries is even trickier, because health care systems differ radically in their financing i and organisation, i and in the social ilgoals they set out to achieve.

10 Standing on the shoulders of giants: OECD Framework (2001) Source: Hurst, J. and Jee Hughes, M. (2001) Performance measurement and performance management in OECD health systems, OECD Labour Market and Social Policy Occasional Papers, no. 47, OECD Publishing.

11 Control Knobs Framework (2003) NB: no Equity component

12 WHO (2007) Building Blocks Source: World Health Organization (WHO). (2007) Everybody s business: Strengthening health systems to improve health outcomes. WHO s framework for action. Geneva: WHO Document Production Services.

13 Atun Systems Framework (2008)

14 Aday Anderson Health System Framework (2004)

15 Commonwealth Fund Framework (2006) Source: Commonwealth Fund. (2006) Framework for a high performance health system for the United States, New York: The Commonwealth Fund.

16 Framework WHO (2000) WHO (2007) Control Knobs (2003) Atun (2008) Aday (2004) Health System Functions Resource Generation Financing Service Provision Stewardship Service Delivery Health Workforce Information Medical products, vaccines and technologies Financing Leadership and Governance Financing Payment Organization Regulation Behaviour Financing Organization and Regulation Resource Allocation Provision Health Policy Structure (delivery system, population at risk, environment) Process (realised access, health risks)

17 Framework Intermediate Objectives Ultimate Objectives WHO (2000; Access Health: level and distribution 2007) Coverage Responsiveness: level and distribution Quality Fairness in financing Safety Efficiency OECD (2001) Control Knobs (2003) Atun (2008) Aday (2004) Commonwealth Fund (2006) Efficiency Quality Access Equity Choice Efficiency Effectiveness Effectiveness Equity Efficiency High quality care Efficient care Access and equity System and workforce innovation and improvement Health: level and distribution Responsiveness and access: level and distribution Equity Macroeconomicand and MicroeconomicEfficiency Health status Consumer satisfaction Risk protection Health Consumer satisfaction Financial risk protection Health and Well being Long Healthy and Productive Lives

18 Terms like Efficiency and Responsiveness are particularly difficult Efficiency WHO: Actual goal attainment achieved related to what could be achieved given resources available OECD: Microeconomic efficiency (measured health system productivity as compared to its maximum attainable), & Macroeconomic efficiency (what effect a change in the level of resources would have on the desired level of health houtcomes and responsiveness compared to other goods and services) Commonwealth Fund: Efficient (not wasteful) care delivery and insurance administration, delivered at the right time and right setting and where new innovations can be evaluated for both effectiveness and value. Control Knobs: Producing society s goals at a minimum cost: Technical/Production efficiency (producing outputsin the right way ) & Allocative efficiency (producing the right outputs ). Aday: Production efficiency (combining inputs to produce services at the lowest cost) & Allocative efficiency (combining inputs to produce maximum health improvements given available resources.

19 Responsiveness WHO: Respect for persons (health system and health provider s respect for dignity, autonomy, confidentiality); and Client orientation (right to prompt attention to health needs, basic amenities of health services, access to patient social support networks, choice of institutions providing care) OECD: Not clearly defined, encompasses notions of patient satisfaction, patientacceptabilityandpatientexperienceincluding acceptability and experience including access Commonwealth Fund: Not explicitly defined but included in definitions of quality and access. Control Knobs: Uses the term citizen satisfaction to indicate the degree to which citizens are satisfied with the health services provided by the health sector.

20 making operationalization and comparison difficult (here: responsiveness/ patient experience domain)

21 What are the Health system boundaries? Source: Murray, CL. and Evans, DB. (2003) Health systems performance assessment: Debates, Methods and Source: Murray, CL. and Evans, DB. (2003) Health systems performance assessment: Debates, Methods and Empiricism. Geneva: World Health Organization.

22 Different definitions of boundaries... Health system boundary WHO: The resources, actors and institutions related to the financing, regulation and provision of health actions. Where health actions are any set of activities how primary intent is to improve or maintain health. OECD: The health care system, notincluding public health activities or other wider issues. Commonwealth Fund: The way in which health care services are financed organized and delivered dli dto meet societal goals for health. h It includes the people, institutions, and organizations that interact to meet the goals, as well as the processes and structures that guide these interactions. WHO Commonwealth Fund OECD

23 and conceptualizations of health outcomes Health WHO: Health of the population at different parts of the life cycle, including theeffects effects ofmorbidity andpremature mortality. OECD: Health outcomes are changes in health status brought about by health care, or health system, activities. Commonwealth Fund: Health outcomes are defined as the capacity of the health care system to contribute to long, healthy and productive lives.

24 MEIN EIGENES META- MODELL

25 Bedarfs- Personal: genügend g und gut qualifiziert? gerechter Institutionen von hohem Standard? Zugang? Technologien effektiv? Qualitativ hochwertige Ergebnisse? Umwelt Ernährung/ Landwirtschaft Gesundheit der Bevölkerung Andere Politikbereiche Ressou urcengener ration adäquat? Techno-logien Technologien Finanzielle Ressourcen Patienten Strukturen Faire und nachhaltige Finanzierung? Prozesse/ Lit Leistungen Human- ressourcen Direkte Ergebnisse: Qualität, Zufriedenheit Medizinische Versorgung Leistungen responsiv (zu Erwartun- gen), angemessenen, koordiniert? Gesund- heits- Outcome Wieviel? Ist es das wert?

26 Universeller Versicherungsschutz, breiter Leistungskatalog, begrenzte Zuzahlungen Gesundheit der Bevölkerung (Re)Lizensierung von Professionellen; ;(Re)Akkreditierung von Institutionen; Mindestmengen; Health Technology Assessment Umwelt Ernährung/ Landwirtschaft Andere Politikbereiche Qualitätsindikatoren; Register; Patientenbefragungen -> Transparenz Patienten Strukturen Prozesse/ Lit Leistungen Human- ressourcen Direkte Ergebnisse: Qualität, Zufriedenheit Gesund- heits- Outcome Techno-logien Technologien Finanzielle Ressourcen Medizinische Versorgung Do the right thing : ex ante Leitlinien/ Disease Management Programme; ex post Reviews Do the thing right : Qualitätsindikatoren

27 Life expectancy at birth has increased by more than 10 years in OECD countries since 1960, reflecting a sharp decrease in mortality rates at all ages

28 Higher health spending per capita is generally associated with higher life expectancy, although this link tends to be less pronounced in countries with higher spending 2009 (or latest year available)

29 Umwelt Lifestyle Gesamtmortalität/ Lebenserwartung Sozio-ökonomischer Status/ Bildung etc. Gesundheitsversorgung Med. vermeidbare Sterblichkeit (Avoidable mortality)

30 The concept of avoidable mortality (AVM; also amenable to health care ) Deaths from certain causes that should not occur in the presence of timely and effective health care Introduced by David Rutstein in the 1970s (originally for quality assurance purposes) Walter Holland published European Community Atlas of Avoidable Deaths in 1988; intends to provide warning signals of potential shortcomings in health care delivery Mackenbach et al. argue that associations between AVM and health care services are rather weak and inconsistent. Most health care measures only reflect quantity and not quality. Many studies use insufficient set of covariates. Nolte and McKee (2002) reviewed list of amenable causes of death

31 Avoidable/amenable causes of death: Nolte & McKee (2002) Todesursache ICD 10 Alter Todesursache ICD 10 Alter Bösartige Neubildung der C Bösartige Neubildungen des Hodens C weiblichen Brust Hypertonie und I Morbus Hodgkin C Hochdruckkrankheiten I15 Krankheiten zerebrovaskulaeres I Leukaemie C91-95 <15 System Ischaemische h I Krankheiten der Schilddrüse E Herzkrankheiten*0.5 Bösartige Neubildung der C Diabetus mellitus E Luftröhre, der Bronchien und der Lunge Chronische h Leberkrankheiten kh K Chronische h rheumatische h I und Zirrhose Herzkrankheiten Kraftfahrzuegunfälle V01-V99 Alle Krankheiten der Atmungsorgane J00-09, 1-14 J20-99 Infektiöse Darmkrankheiten A Pneumonie und Grippe J Typhus A01 A Magengeschwür g K Diptherie A35 Krankheiten der Appendix K Tetanus A40-41 Eingeweidebrüche K Sepsis A80 Gallensteinleiden K Poliomyeltis M86 Osteomyelitis M46,2 Keuchhusten/ Pertussis A Nephritis, Nephrotisches Syndrom N und Nephrose N17-19 N25-27 Masern B Prostatahyperplasie N Tuberkulose A Schwangerschaft, Geburt und O00-99 alle B90 Wochenbett Sonstige bösartige Neubildungen der C Bestimmte Affektionen, die ihren P00-96 alle Haut Ursprung in der Perinatalzeit haben Bösartige Neubildungen der Zervix uteri C Angeborene Fehlbildungen des Q Kreislaufsystems

32

33 In most EU/ EEA countries, persons s report few problems pobe swt with access

34 The health sector has become the main sector for employment with wide variation across countries

35 The number of physicians per capita has increased in all OECD countries since 2000 (except in Slovakia)

36 F Health expenditure per capita varies widely across OECD countries

37 F OECD countries allocate 9.5% of their GDP to health - with variation from 17.4% in the United States to 6% in Turkey

38 The number of MRI units and CT scanners: enormous variation between countries

39 The average length of stay for acute care has fallen in nearly all OECD countries

40 but large variations still exist for most conditions

41 Variations is even larger for certain procedures; here: coronary angioplasty

42 Variations is even larger for certain procedures; here: hip implants (I)

43 Variations is even larger for certain procedures; here: hip implants (II) and knee implants