Political devolution and the health services in Great Britain.

This article reviews the effects of political devolution on health care in the countries of Great Britain at the end of the first term of the new political institutions created in 1999. In the light of the powers transferred, an assessment is made of the nature and extent of policy autonomy exercised by the devolved administrations. The author considers the question of whether political devolution is leading to local variations in health care provision that threaten established concepts of equity in a U.K. National Health Service. Policy areas discussed include the personal care of older people, mental health, governance, competition, the role of the private sector, and the health care workforce. Also discussed are the dynamics of intergovernmental relations in the longer term, including the effects of the developing European Union. The article concludes by assessing the extent to which the individual countries within Great Britain are likely to develop health care systems with distinctive identities.     

Privatization of health systems with care: A message to East Europe from western systems

Eastern European countries are experiencing major changes in their political and socio-economic systems. Similarly, health care systems are facing major policy changes. The enthusiasm for privatization and decentralization, without adequate preparation, is likely to produce unfavorable results unless careful planning and analysis of policy options is followed. This paper analyses the current status, problems and policies of health care systems in Eastern Europe. It raises the argument that privatization may not be the solution, based on western countries’ experiences.     

A realistic approach to the evaluation of the quality management movement in health care systems: a comparison between European and African contexts based on Mintzberg's organizational models

The quality movement is gaining momentum worldwide in the field of health care. Initiated in industrialized countries, it steadily grows in Africa. However, there is no evidence that approaches designed to address issues in a given organizational context have the same effect in another one where issues present differently. Along the epistemological paradigm of realistic evaluation proposed by Pawson and Tilley, we use Mintzberg's organizational models to compare the configurations of European and African health care organizations and the trends followed by the quality management movement in both contexts. We illustrate how European health systems traditionally emphasize professional autonomy while African health systems are structured as command and control hierarchical systems. We illustrate how the quality movement in Europe emphasizes standardization of procedures, a characteristic of a mechanistic organization, while excessive standardization is part of the quality problem in Africa. We suggest that instilling professionalism may be a way forward for the quality movement in Africa to improve patient focus and responsiveness of responsible professionals. We also suggest that our interpretation of broad trends and contrasts may be used as a useful departure point to study the wide contextual diversity of the African experience with quality management.     

The changing context of Western European healthcare systems: convergence versus divergence in nursing problematics

Many countries reorganizing their health services are drawn toward similar reform programs and tend to experience what seem to be similar problems relating to implementation outcomes. One such problem is the major crisis within the nursing profession relating to the labor market, working conditions and level of autonomy. This research examines the thesis that the profile of nursing problems is global (the 'convergence' thesis) by comparing the changing hospital contexts nursing has been confronting in 20 Western European countries between 1990 and 2001. The analysis indicates that in spite of growing convergence, the divergence in patient care processes, workforce composition and resources allocated for care is still rather remarkable and that similarity or divergence between countries changes over time. This contextual variability highlights why problems such as the crisis of the nursing profession must be analysed from a divergent rather than a convergent perspective.     

Health indicators and the organization of health care systems in western Europe.

OBJECTIVES. This study investigated the association between health care systems and health indicators in developed countries. METHODS. Cross-national comparisons were conducted with regression analysis between 17 Western European countries with two types of health care systems: national health services and social security systems. RESULTS. Health care expenditures were inversely correlated to potential years of life lost to females and to infant mortality rates; they were positively correlated to life expectancy for females. Regression models predicted that countries with national health services systems would have lower infant mortality rates at similar levels of gross domestic product (GDP) and health care expenditures. Finally, increases in health care expenditures would decrease the ratio of observed to predicted infant mortality rates according to GDP; this decrease would be greater in countries with national health services than in those with social security systems. The model predicted this difference to be about 13% at average levels of health expenditures. CONCLUSIONS. National health services seem to be more efficient at producing lower infant mortality rates than social security systems in Western European countries.     

Primary care in Europe: entering the age of austerity

Many European countries have well-developed health systems that offer universal access to health services and which have a strong primary care sector. However, as the financial crisis in Europe progresses, it is leading to significant cutbacks in publicly funded health services. A key objective for primary care physicians will therefore be to work in an environment where resources will be much more limited than in the past. In the longer term, the role of primary care physicians in European health systems will continue to expand to meet the aim of shifting health services to the generally more cost-effective setting of primary care.     

Managing the transitions: a Western European View of Health Care Development in Eastern Europe

The health care systems of Eastern Europe are undergoing rapidchange. Ministries of Health in the Eastern countries are turningto the West for solutions. This paper offers an overview ofthe health systems of four Eastern European countries, the catalystsof reform in those countries, and possible strategies for managingthe transitions. The objectives of health care reform are outlinedas well as the key issues and obstacles facing Eastern governmentsas they attempt to change both the structure and function ofhealth care systems.     

The Role of the World Health Organization on Pharmaceuticals in Europe

The World Health Organization (WHO) is the specialized agency of the UN on public health. It gives worldwide guidance in the field of health, sets global standards for health, cooperates with governments to strengthen national health care programs, and develops and transfers appropriate health technology, information, and standards. Within the WHO European region, health status and health expenditures vary greatly. In this paper, disparities between health status, health services, and health care expenditures between countries of the WHO European region are presented. The objectives, performance, and dilemmas facing health care systems are discussed, including the recent performance ranking published by the WHO. The paper focuses particularly on access to medicines, their appropriate use, and rising drug expenditures. Strategies used by European countries to improve drug use and contain health care expenditures are outlined. Finally, the future of pharmaceuticals and public health is explored.     

Early health system responses to the COVID-19 pandemic in Mediterranean countries: A tale of successes and challenges

This paper conducts a comparative review of the (curative) health systems’ response taken by Cyprus, Greece, Israel, Italy, Malta, Portugal, and Spain during the first six months of the COVID-19 pandemic. Prior to the COVID-19 pandemic, these Mediterranean countries shared similarities in terms of health system resources, which were low compared to the EU/OECD average. We distill key policy insights regarding the governance tools adopted to manage the pandemic, the means to secure sufficient physical infrastructure and workforce capacity and some financing and coverage aspects.We performed a qualitative analysis of the evidence reported to the ‘Health System Response Monitor’ platform of the European Observatory by country experts. We found that governance in the early stages of the pandemic was undertaken centrally in all the Mediterranean countries, even in Italy and Spain where regional authorities usually have autonomy over health matters. Stretched public resources prompted countries to deploy “flexible” intensive care unit capacity and health workforce resources as agile solutions. The private sector was also utilized to expand resources and health workforce capacity, through special public-private partnerships. Countries ensured universal coverage for COVID-19-related services, even for groups not usually entitled to free publicly financed health care, such as undocumented migrants.We conclude that flexibility, speed and adaptive management in health policy responses were key to responding to immediate needs during the COVID-19 pandemic. Financial barriers to accessing care as well as potentially higher mortality rates were avoided in most of the countries during the first wave. Yet it is still early to assess to what extent countries were able to maintain essential services without undermining equitable access to high quality care.     

Is primary health care progressing in Europe?

Primary health care (PHC) is the key to attaining the goal of health for all (HFA) by the year 2000. Also the European countries have accepted the declarations and WHO resolutions related to global and European HFA strategies. However, the implementation of regional and national strategies has met with many obstacles, caused by reluctant attitudes and poor planning and management systems. In this review the objective of PHC in industrialized countries, the evaluation process of HFA strategy, and progress in PHC in Europe in the 1980s are discussed. Lack of defined national objectives, and health information systems which are not adopted to purposes of monitoring progress in PHC are causing most of the problems in evaluation. There is a clear positive development in PHC resources and organization in the Nordic countries. Generally speaking PHC is progressing very slowly in Europe, if there is any progress at all. This can be said both about organization of health care, planning and management systems and about application of PHC principles like community participation and intersectoral collaboration. The national health information systems should be quickly revised to allow more exact monitoring of progress towards the 38 European targets and additional national targets.     

Do family physicians need more payment for working better? Financial incentives in primary care

IntroductionFinancial incentives are widely used in health services to improve the quality of care or to reach some specific targets. Pay for performance systems were also introduced in the primary health care systems of many European countries.ObjectiveOur study aims to describe and compare recent existing primary care indicators and related financing in European countries.MethodsLiterature search was performed and questionnaires were sent to primary care experts of different countries within the European General Practice Research Network.ResultsTen countries have published primary care quality indicators (QI) associated with financial incentives. The number of QI varies from 1 to 134 and can modify the finances of physicians with up to 25% of their total income.ConclusionsThe implementations of these schemes should be critically evaluated with continuous monitoring at national or regional level; comparison is required between targets and their achievements, health gains and use of resources as well.     

Evaluations of health interventions in social insurance-based countries: Germany,the Netherlands,and Austria

Health Technology Assessment (HTA) in social insurance-based, or so-called 'Bismarck' health care systems (Germany, Austria, and the Netherlands) has taken a different course than in either taxed-based (Sweden, Norway, United Kingdom, and Spain) or private health care systems (such as the United States). The culture of informed decisions supported by transparent and evidence-based evaluations of health interventions was hindered by the strong professional autonomy and sectoral interests in Germany and Austria for a long time. On the other hand, HTA has a long-standing tradition in the Netherlands. In all three countries sickness funds play an important role in implementing evaluations-as a policy tool-by linking reimbursement to explicit proof of effectiveness in both new and established interventions. This article focuses on the obstacles and opportunities for HTA in Germany, Austria and the Netherlands as countries with insurance-based health care systems.     

Rethinking priorities in hospital management: a case from Central Asia

ObjectivesTo evaluate post-Soviet aspects of hospital management in Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan, considering indicators of health care and information on planning processes and factors that affect strategy in their hospitals.MethodsData on indicators of health care were obtained from government agencies, the WHO and the World Bank. A survey of hospital managers in each of the countries was undertaken to obtain opinions on matters influencing the operation of their organizations.ResultsThere was some increase in health expenditure for three countries and a recent decline for Kyrgyzstan. All countries had levels of out of pocket expenditure that were higher than recommended by WHO. Hospital bed occupancy was relatively constant. Average length of stay was higher than in European health systems. Managers in all countries reported greater motivation of staff in their work as a planning benefit. Difficulties with the implementation of plans were greater for Kyrgyzstan than the other countries. Inappropriate assessment during planning seemed important for two countries and changes in environment during implementation for two others. Issues with health policy and regulation, new health technologies, and changes in health behaviour and morbidity were considered significant by managers from all countries.ConclusionsThe health care indicator data and survey findings may reflect differences between the countries in the rate of reorganization of hospital sectors, available resources and political circumstances. They point to areas in need of attention for future hospital planning and challenges for managers in maintaining essential health services.     

Market strategies for publicly financed health care systems.

Most West European countries have health care systems financed by social insurance funds. In these pluralistic systems, decision-making processes are complex and involve many factors. The present paper focuses on the decision-making behavior of public authorities in health care. It is stressed that understanding the functioning of the political market is essential for explaining the development and performance of health care systems. This political market receives relatively little attention from economists. Specific mechanisms as they can be observed in this market are discussed, and the paper concludes with a plea for reducing the role of government in planning and price-setting in health care.     

Social austerity versus structural reform in European health systems: a four-country comparison of health reforms.

Cost containment has captured the attention of health policymakers in most OECD countries, and deliberations about creating powerful financial incentives dominate health care politics. Some European health systems are now implementing hospital payment schemes that mirror the U.S. model of diagnosis-related groups (DRGs) and are raising premiums and copayment levels in an effort to limit public expenditures. Though financial incentives may indeed help rein in health expenditures, focusing predominantly on financial incentives hinders due consideration of needed structural reforms that improve the continuity, quality, and appropriateness of health care service delivery. This article focuses on the structural specifics of two legally enacted health insurance systems (Germany and Austria) and two national health systems (Great Britain and Denmark) to discuss the influence of structural characteristics on cost-containment efforts. Structural reform strategies discussed include increasing reliance on general practitioners, improving coordination of community and hospital-based specialty care, addressing the stark divide between ambulatory and hospital-based care that exists in some European health systems, and improving continuity of care by better integrating medical and social care sectors. Also discussed is the relative focus on financial incentives versus structural deficits in recent European-health care reform strategies.     

Privatizing health care: caveat emptor

Many Western European countries are moving toward privatization of their health care systems. The United States' health care system, since it is almost entirely privatized, is therefore worthy of study. Doing so raises several questions. How is privatization being managed in the US? How could its management be improved? What management lessons must be kept in mind if it is to be used effectively? What potential pitfalls should European countries consider as they move toward greater privatization? With operating costs, European countries must avoid the mistakes that have led to dramatic increases in annual health care costs in the US, simultaneous with reductions in access and quality. Doing so requires designing systems that promote hospital behavior consistent with a country's health objectives. With capital costs, an approach must be designed that allows policy-makers to work closely with both managers and physicians in order to make strategically sound choices about access and quality. Such an approach will require physicians to incorporate their clinical judgments into community standards of care, and to adopt a regional (rather than an institutional or personal) perspective in the determination of any incremental capital expenditures. By making regulation proactive and strategic, rather than punitive, health policymakers in Western Europe can achieve the best privatization has to offer without feeling the sting of its unintended consequences. In so doing they can help to move their health systems toward achieving the multiple and illusive goals of access, quality and reasonable cost.     

Regional health budgeting in Western Europe

This article distinguishes in the first section three characteristics of regional budgeting in health care systems: geographical division of budgets, regional financial limits, and policy freedom for regional authorities. Following these and more general elements of regional budgeting systems sections 2 to 5 describe the situation in the U.K., Sweden, The Netherlands, and some other European countries. The first two countries have a developed regional budgeting system for health services paid by taxation. Other European countries are developing regional budgeting models which are to be combined with a social insurance system. Of these countries, the Netherlands are discussed in some detail. Based on the experiences with regional budgeting in different countries three hypotheses are generated which require further empirical research. They are: (1) One management tier on a regional level--or municipal or provincial level--is a condition for a regional budgeting system which contributes more to an integration of health services than a two-tier system. (2) Countries with a regional budgeting system with a regional financial limit superimposed by the state seem to spend a smaller percentage of their gross national product than other countries. (3) Countries with policy freedom on a local level show a faster growth rate for primary care than for hospital care.     

Primary care workforce development in Europe: An overview of health system responses and stakeholder views

Better primary care has become a key strategy for reforming health systems to respond effectively to increases in non-communicable diseases and changing population needs, yet the primary care workforce has received very little attention. This article aligns primary care policy and workforce development in European countries. The aim is to provide a comparative overview of the governance of workforce innovation and the views of the main stakeholders. Cross-country comparisons and an explorative case study design are applied. We combine material from different European projects to analyse health system responses to changing primary care workforce needs, transformations in the general practitioner workforce and patient views on workforce changes. The results reveal a lack of alignment between primary care reform policies and workforce policies and high variation in the governance of primary care workforce innovation. Transformations in the general practitioner workforce only partly follow changing population needs; countries vary considerably in supporting and achieving the goals of integration and community orientation. Yet patients who have experienced task shifting in their care express overall positive views on new models. In conclusion, synthesising available evidence from different projects contributes new knowledge on policy levers and reveals an urgent need for health system leadership in developing an integrated people-centred primary care workforce.     

The role of medical associations in quality assurance

The European governments have decided to install quality assurance programmes in their health care systems by 1990. Quality is being defined as: "safe, effective, efficient, acceptable and appropriate care rendered by competent providers on the basis of efficacious technology". A wide range of methodologies is available for the assessment of each or several of the different dimensions of quality. Implementing these methods can be the role of either voluntary organizations or of mandatory ones. Medical associations could assume a leadership role in the field of quality assurance and contribute to the development of data-poor assessment systems and to the strengthening of existing information and management systems. The prevailing concept of clinical autonomy and its use in the practice of medicine should be revised.