Examining sociopolitical elements of health system reform: The experience of Singapore and Taiwan

This essay suggests five sociopolitical dimensions that influence the success of health system reforms. It examines the experience of two high-income Asian countries, Singapore and Taiwan, and illustrates how these five dimensions matter. These five sociopolitical dimensions are public trust, perceived government performance, political legitimacy, equity/solidarity, and demand for choice. Public trust in government, perceived government performance, and the legitimacy of political authorities were necessary for governments in both countries to enact key reforms. Public perceptions of government capacity combined with public conceptions of equity were deliberated and clarified as stakeholders sought to reach consensus based on values upheld by segments of each society. Nevertheless, these elements alone are not enough to sustain major institutional reforms in light of ongoing social, political, and demographic changes. This essay provides a different approach to traditional policy cycle models and seeks to emphasize stewardship and governance in health systems.     

Political and welfare state determinants of infant and child health indicators: an analysis of wealthy countries

Economic indicators such as income inequality are gaining attention as putative determinants of population health. On the other hand, we are just beginning to explore the health impact on population health of political and welfare state variables such as political orientation of government or type of medical care coverage. To determine the socially structured impact of political and welfare state variables on low birth weight rate, infant mortality rate, and under-five mortality rate, we conducted an ecological study with unbalanced time-series data from 19 wealthy OECD countries for the years from 1960 to 1994. Among the political/welfare state variables, total public medical coverage was the most significant predictor of the mortality outcomes. The low birth weight rate was more sensitive to political predictors such as percentage of vote obtained by social democratic or labor parties. Overall, political and welfare state variables (including indicators of health policies) are associated with infant and child health indicators. While a strong medical care system seems crucial to some population health outcomes (e.g., the infant mortality rate), other population health outcomes might be impacted by social policies enacted by parties supporting strong welfare states (the low birth weight rate). Our investigation suggests that strong political will that advocates for more egalitarian welfare policies, including public medical services, is important in maintaining and improving the nation's health.     

新医改的新政治经济学分析

运用新政治经济学谱系中的制度变迁理论、公共选择理论和委托代理理论,对新医改中的有关问题进行初步分析,探讨新医改中正确处理政府、市场与医疗部门之间关系的思路与方法,阐述了新政治经济学在医改中的应用与发展。     

Health services reform in Poland: issues in recent developments

After ten years of debate and discussion, the political situation within Poland finally allows the possibility to implement basic reforms in the health care system. Parallel development of the political and technical aspects of the reform has now lead to a final proposal for fundamental reforms in health system responsibility, financing and management. This article describes the current conceptual developments and the political and social context for these final reform proposals at the time of their submission to the government. The primary changes suggested are aimed at increasing the awareness of local, regional and national administrations, health care professionals and the general public that health care has a cost, and that resources must be used carefully if they are to cover health needs. In addition, 'health care' as a term must be extended to include factors and activities besides direct medical services. Such factors as air and water quality, diet, smoking and alcohol consumptions are examples of matters which will also be included in the focus of health system planners. A key element of the organisational reforms is decentralisation of responsibility for health care planning and administration within the framework of nationally set standards and priorities. Based on local decisions, the current basic organisation unit of health care delivery, the ZOZ or integrated health care units, will be redefined and either decomposed into their component services or receive newly defined responsibilities more adapted to the local realities of available manpower and medical facilities. In addition, the development of a private health care sector complementing and even competing with the public services sector will be actively encouraged.     

Changes in the demand for private medical insurance following a shift in tax incentives

The 1998 Spanish reform of the Personal Income Tax eliminated the 15% deduction for private medical expenditures including payments on private health insurance (PHI) policies. To avoid an undesired increase in the demand for publicly funded health care, tax incentives to buy PHI were not completely removed but basically shifted from individual to group employer-paid policies. In a unique fiscal experiment, at the same time that the tax relief for individually purchased policies was abolished, the government provided for tax allowances on policies taken out through employment. Using a bivariate probit model on data from National Health Surveys, we estimate the impact of said reform on the demand for PHI and the changes occurred within it. Our findings indicate that the total probability of buying PHI was not significantly affected by the reform. Indeed, the fall in the demand for individual policies (by 10% between 1997 and 2001) was offset by an increase in the demand for group employer-paid ones. We also briefly discuss the welfare effects on the state budget, the industry and society at large.     

Market reforms and public incentives: finding a balance in the Republic of Macedonia

The Republic of Macedonia is undertaking sweeping reforms of its health sector. Funded by a World Bank credit, the reforms seek to improve the efficiency and quality of primary health care (PHC) by significantly strengthening the role of the market in health care provision. On the supply-side, one of the key reform proposals is to implement a capitation payment system for PHC physicians. By placing individual physicians on productivity-based contracts, these reforms will effectively marketize all PHC provision. In addition, the Ministry of Health is considering the sale or concessions of public PHC clinics to private groups, indicating the government's commitment to marketization of health care provision. Macedonia is in a unique position to develop a new role for the private sector in PHC provision. The private provision of outpatient care was legalized soon after independence in 1991; private physicians now account for nearly 10% of all physicians and 22% of PHC physicians. If the reforms are fully realized, all PHC physicians-over 40% of all physicians-will be financially responsible for their clinical practices. This study draws on Macedonia's experience with limited development of private outpatient care starting in 1991 and the reform proposals for PHC, finding a network of policies and procedures throughout the health sector that negatively impact private and public sector provision. An assessment of the effects that this greater policy environment has on private sector provision identifies opportunities to strategically enhance the reforms. With respect to established market economies, the study finds justification for a greater role for government intervention in private health markets in transition economies. In addition to micro-level payment incentives and administrative controls, marketization in Central and Eastern Europe requires an examination of insurance contracting procedures, quality assurance practices, public clinic ownership, referral practices, hospital privileges, and capital investment policies.     

公私伙伴关系促进医疗服务供给侧改革的国际经验及其启示

基于公私伙伴关系(PPP)的相关理论与概念,本文从管理理念的变革,财政预算的压力,技术创新与服务模式的转变及健康服务业的发展等方面系统阐述了PPP模式在医疗服务领域的发展动力,并结合国际社会在医疗服务领域引入PPP模式的实践,总结了部分国家在改革实践中所取得的效果与存在的风险;研究发现,在医疗服务领域引入PPP模式对促进政府职能转变,缓解政府的筹资压力,特别是推进医疗服务供给侧的结构性改革,提升医疗服务系统对消费者需求的反应性,实现其"物有所值"的最大化等具有一定的促进作用与现实意义;但是,在实践中要处理好政府角色的定位,趋利行为与公益性,垄断与监管等方面的关系。相关的启示是,在深化医改的实践中要树立开放、包容、共享的创新发展理念,并进一步完善相关的政策法规,提升监督管理能力。     

新医改中公立医院改革的几个问题

对卫生管理体制、公立医院公益性、医疗资源合理使用等三个问题提出笔者的观点,认为管理体制改革关键是要进一步按照大部制改革的方向推进医疗、医药、医保统一管理,以理清政府"管"和公立医院法人"办"的职能界面为方向推进管办分开;强化公立医院公益性,关键是要科学设计一系列激励和约束机制;促进医疗资源合理使用,关键是要逐步建立分级医疗制度。     

Critical analysis of health priorities determination in France

Since the mid 1970's, reforms to the health care system were aimed at controlling expenditures. Furthermore, there was not much of a relationship between public health policies and expenditure control policies. The reforms of 1996 aimed to introduce a new paradigm. The French health care system, based until then upon the biomedical model, now must adopt public health tools: Definition of health objectives; Development of priorities; Evaluation; Allocation of resources based on needs; Public debates. The objective of this study is to evaluate the move toward defining priorities, three years after the introduction of this reform. The study focused on the type of priorities implemented (e.g. implicit or explicit priorities, access to health care services, or severity of health problems) and their links to the allocation of resources; and the practical development of priorities (e.g. political or technocratic procedure, the role of public debates). In France, priorities are defined by health problem and not by service. They are explicit, but the link to allocation of resources isn't clear. Despite a wide consultation, the system of defining priorities is more technocratic than political. Moreover, the system is more concerned with including health professionals (doctors, administrators) in this new approach to public health, than with taking public opinion into account.     

Political analysis of the conception of the Polish National Health Fund

Background After the fall of communism, Poland implemented one of the widest reaching programmes of socio-economic reforms. However, in comparison health system reforms were less radical. At the end of the 1990s a change process had been started, but the political fight for power has heavily influenced the health reforms and led to two different reform concepts being implemented over a period of a few years. Aim The paper assesses the chances of implementation of the reform proposed in 2001 to recentralise health financing and organisation by replacing regional sickness funds by a National Health Fund. A hypothetical model is proposed which is placed at the start of the reforms and compares the model to the actual political course observed. Methods PolicyMaker software was used for a political mapping analysis. The policy content (goals and mechanisms) was based on official political documents as well as verbal declarations made by key policymakers in the media, newspapers and magazines. Results The analysis showed that the political situation was in favour of the government implementing a single National Health Fund. Nevertheless, this generated a strong resistance by the political opposition, experts and health care workers which could be a substantial obstacle for the realisation and effectiveness of the implemented model. The feasibility of the project could have been increased by implementing a number of strategies aimed at modifying the attitude of key stakeholders and by introducing the proposed reform as part of an overall improvement of the work environment for health professionals. Conclusions The concept of a National Health Fund generated important opposition against the proposed changes in the health care system. With its majority in Parliament, the government was nevertheless able to establish the new system. The actual course of the reforms however contained a large number of formal errors, which led the Constitutional Court to rule the reform as unconstitutional. Substantial imperfection of the reform caused a destabilization of the whole health care system. In addition, defeat of the reform caused a decrease of electoral support for the governing coalition.     

The political context of social inequalities and health

This analysis reflects on the importance of political parties, and the policies they implement when in government, in determining the level of equalities/inequalities in a society, the extent of the welfare state (including the level of health care coverage by the state), the employment/unemployment rate, and the level of population health. The study looks at the impact of the major political traditions in the advanced OECD countries during the golden years of capitalism (1945-1980) -- social democratic, Christian democratic, liberal, and ex-fascist -- in four areas: (1) the main determinants of income inequalities, such as the overall distribution of income derived from capital versus labor, wage dispersion in the labor force, the redistributive effect of the welfare state, and the levels and types of employment/ unemployment; (2) levels of public expenditures and health care benefits coverage; (3) public support of services to families, such as child care and domiciliary care; and (4) the level of population health as measured by infant mortality rates. The results indicate that political traditions more committed to redistributive policies (both economic and social) and full-employment policies, such as the social democratic parties, were generally more successful in improving the health of populations, such as reducing infant mortality. The erroneous assumption of a conflict between social equity and economic efficiency, as in the liberal tradition, is also discussed. The study aims at filling a void in the growing health and social inequalities literature, which rarely touches on the importance of political forces in influencing inequalities. The data used in the study are largely from OECD health data for 1997 and 1998; the OECD statistical services; the comparative welfare state data set assembled by Huber, Ragin and Stephens; and the US Bureau of Labor Statistics.     

深化广州市医疗卫生体制改革的对策探析

加大政府投入，提高公立医院的公益性是深化改革的突破口：调整政策取向，引导卫生资源合理配置是深化改革的重要举措：建立覆盖全民的社会医疗保险制度是深化改革的根本保证。     

社区卫生服务收支两条线改革认识误区的思考

厘清社区卫生服务公益性内涵和收支两条线制度作用机理是实现社区卫生服务改革目标的前提。当前社区服务收支两条线改革存在将公益性机制的建立简单地等同于切断趋利行为、加大政府投入、减免医疗费用的认识误区。在厘清收支两条线改革认识误区的基础上,进行社区卫生服务外在形态机制、内在运行机制和绩效考核机制"三位一体"的综合改革,是实现社区卫生服务公益性的有效路径。     

探讨实现医院公益性的保障机制及其基本框架

结合当前卫生体制改革思路,明确医院公益性的定位与职能,探讨保障医院公益性的制度安排与机制设计原则,研究保障医院公益性运行机制的基本框架,为进一步建立医院公益性保障机制模型奠定基础,为政府有关决策部门制定医院改革与发展的政策与法规提供理论支撑和决策依据。     

美国医改实施的进展、前景与启示

美国医改实施三年来,在扩大医保可及性、改革医疗服务市场、降低医疗费用和改进服务质量方面取得较大进展,但许多触及既得利益集团的核心改革政策如建立保险交易所、改革支付方式、削减部分福利项目、提高富人税率等开源节流措施尚未正式启动,这将成为奥巴马连任后面临的主要挑战。美国医改鼓励服务的整合、改革支付制度、重视预防保健服务等做法值得中国医改借鉴,同时以商业医疗保险为主导的保险体系暴露出的弊端也启示中国政府以更加审慎的态度发展商业医疗保险。     

Navigating the political and technical challenges of developing a national HRH strategy: a case study in Greece

Healthcare workforce reforms to enable implementation of government health policies require government leadership, and commitment of various stakeholders, but workforce reforms often meet resistance from powerful stakeholders. We use Kingdon’s Multiple Streams framework to explain how in 2017, in Greece, the interplay between problems, policy and politics led to government marshalling support from experts to develop a National HRH Strategy. A window of opportunity for healthcare workforce reforms occurred because of the Ministry of Health’s acknowledgement of structural workforce problems (problem stream), the introduction of policies and decrees on Primary Health Care and Public Health, and availability of globally formulated HRH policy solutions (policy stream). Additionally, interest of the government in Universal Health Coverage combined with reform requirements from European loan providers provided political opportunities (politics stream). This experience shows 1) the opportunity for change presented by circumstances; 2) the importance of creating healthcare workforce capabilities within the government to implement a health policy agenda. However, windows of opportunity are short‐lived political interest is fleeting, competing problems may arise, alternative solutions may be proposed or governments may change. We conclude with a key challenge for success: how to assure continued government commitment to HRH reforms in a changing political context.     

价值取向与政治博弈:美国医改政策回眸

美国共和民主两党在医改政策方面主要围绕着居民健康与卫生保健的权利,以及政府与市场在医疗服务领域的作用等不同的价值取向展开长期的政治博弈。通过对从罗斯福到奥巴马历任政府医改政策的分析,探讨不同政党在价值选择、政策抉择和基于政府与市场平衡的医改政策。其政策过程表明:政党的价值取向奠定了医改政策的基本点;医改不仅仅是一个经济问题,也是一个利益整合的政治问题;政府主导和市场竞争的有机结合即"有管理的保健"改革策略是当下一种明智的选择。     

Venezuela's Barrio Adentro: an alternative to neoliberalism in health care.

Throughout the 1990s, all Latin American countries but Cuba implemented health care sector reforms based on a neoliberal paradigm that redefined health care less as a social right and more as a market commodity. These reforms were couched in the broader structural adjustment of Latin American welfare states as prescribed by international financial institutions since the mid-1980s. However, since 2003, Venezuela has been developing an alternative to this neoliberal trend through its health care reform program, Misión Barrio Adentro (Inside the Neighborhood). In this article, the authors review the main features of the Venezuelan health care reform, analyzing, within their broader sociopolitical and economic contexts, previous neoliberal health care reforms that mainly benefited transnational capital and domestic Latin American elites. They explain the emergence of the new health care program, Misión Barrio Adentro, examining its historical, social, and political underpinnings and the central role played by popular resistance to neoliberalism. This program not only provides a compelling model of health care reform for other low- to middle-income countries but also offers policy lessons to wealthy countries.