Health and Welfare Models in a Changing
Europe/World
Parallel Session 2
2. December 2016, 9.00-11.30
Rome, Italy
Marcel Leppée
Health systems:
all the institutions, people and actions
whose primary purpose is to improve
health. WHO, 2000
OBJECTIVES
• Improving people’s health and well being
• Responding to people’s expectations
• Providing protection against the costs of ill-health
HEALTH SYSTEM ≠ HEALTH SERVICES
Health Services are the set of institutions and
programs that provide:
• Direct care to health and disease needs of individuals; and
• Public Health Services for the protection of collective
health, (i.e. the health of communities).
Health Systems Reforms
XX and XXI Centuries
•
•
•
•
•
Up to the 1920s:
1920-1940:
1950-1970s:
1970-80s:
1990s:
Sanitary Campaigns
Social Security systems (Bismarck model)
Welfare State systems” (Beveridge model)
Primary Health Care (Health for All – Alma Ata)
Cost-containment and efficiency driven
(International Financial Institutions)
• 2000 to date:
–
–
–
–
Renewal of Primary Health Care
People Centered Care
Integrated Healthcare delivery
Social Protection in Health
Universal Access to Health and Universal Health Coverage
(Universal Health)
There are about 200 countries on our planet
each country devises its own set of arrangements for
meeting the three basic goals of a health care
system:



keeping people healthy,
treating the sick, and
protecting families against financial ruin from
medical bills.
But we don’t have to study 200 different systems to
get a picture of how other countries manage health
care. For all the local variations, health care systems
tend to follow general patterns.
There are four basic systems.
The Beveridge Model
Named after William Beveridge, the daring social reformer who designed
Britain’s National Health Service.
Health care is provided and financed by the government through tax
payments, just like the police force or the public library.
Many, but not all, hospitals and clinics are owned by the government; some
doctors are government employees, but there are also private doctors who
collect their fees from the government.
These systems tend to have low costs per capita, because the government,
as the sole payer, controls what doctors can do and what they can charge.
Countries using the Beveridge Model or variations on it are:
Great Britain
most of Scandinavia
Spain
New Zealand
Hong Kong still has its own Beveridge-style health care,
because the populace simply refused to give it up when the Chinese
took over that former British colony in 1997.
Cuba represents the extreme application of the Beveridge
approach; it is probably the world’s purest example of total government
control.
The Bismarck Model
Named for the Prussian Chancellor Otto von Bismarck, who
invented the welfare state as part of the unification of Germany in
the 19th century.
This model uses an insurance system — the insurers are called
“sickness funds” — usually financed jointly by employers and
employees through payroll deduction.
Bismarck-type health insurance plans have to cover everybody,
and they don’t make a profit.
Doctors and hospitals tend to be private.
A multi-payer model (Germany has about 240 different funds ).
Tight regulation gives government much of the cost-control clout
that the single-payer Beveridge Model provides.
The Bismarck model is found in:
Germany
France
Belgium
The Netherlands
Japan
Switzerland
to a degree, in Latin America.
The National Health Insurance Model
This system has elements of both Beveridge and Bismarck.
It uses private-sector providers, but payment comes from a
government-run insurance program that every citizen pays into.
Since there’s no need for marketing, no financial motive to deny claims
and no profit, these universal insurance programs tend to be cheaper
and much simpler administratively than American-style for-profit
insurance.
The single payer tends to have considerable market power to negotiate
for lower prices
National Health Insurance plans also control costs by limiting the
medical services they will pay for, or by making patients wait to be
treated.
The classic NHI system is found in:
Canada
Taiwan and South Korea (as newly industrialized
countries have also adopted the NHI model)
The Out-of-Pocket Model
Only the developed, industrialized countries — perhaps 40 of the
world’s 200 countries — have established health care systems.
Most of the nations on the planet are too poor and too
disorganized to provide any kind of mass medical care. The basic
rule in such countries is that the rich get medical care; the poor
stay sick or die.
Hundreds of millions of people go their whole lives without ever
seeing a doctor. They may have access, though, to a village healer
using home-brewed remedies that may or not be effective against
disease.
In the poor world, patients can sometimes scratch together
enough money to pay a doctor bill; otherwise, they pay in
potatoes or goat’s milk or child care or whatever else they may
have to give. If they have nothing, they don’t get medical care.
rural regions of Africa
India
China
South America
Difference United States - all other
Americans have elements of all of them in their fragmented
national health care apparatus.
The United States is unlike every other country
It maintains so many separate systems for separate classes of
people.
All the other countries have settled on one model for
everybody.
Healthcare models
There are two main types of healthcare systems in Europe:
1. The tax-funded model (eg UK, Scandinavia) is a singlepayer, predominantly public, system with salary or capitation
reimbursements, where patients have a choice of providers
and specialist access is regulated through General
Practitioners.
2. The social insurance model (eg Germany, Netherlands,
France) has both multiple payers
and owners of provider assets with fees being levied for
services, where patients have a choice of insurers and direct
access to specialists.
European healthcare systems are in urgent
need of reform. Converging pressures of:
1.
2.
3.
4.
an ageing population,
the growing burden of chronic diseases,
shortages of healthcare workers and
increased demand for care
are significant challenges for healthcare
systems.
Health Services: What pushes the need to change?
Changes in
Demand
Demographics
Epidemiology
People’s
Expectations
Changes in
Offer
Knowledge and
Technology
Work Force Issues
Financial pressure
Social Changes
Globalization
Reforms of the State
Sectorial Reforms
Health
Services
Adapted form Mc Kee, M.; Healy, J. 2002
MODELS OF CARE
A logical framework that defines what services will be provided to
address the health needs, demands and expectations of the
population.
• Bio-Medical Model of Care
• Social Model of Care
• People-Centered Model of Care
Bio-Medical Model of Care
Focuses on the physical or biological
aspects of diseases and illness. It is a
medical model of care practised by
doctors and/or health professional and
is associated with the diagnosis, cure
and treatment of disease.
Bio-Medical Model of Care
 Centered on acute episodic care,
 Supply driven and organized by levels that
fragment care
 Hospital-based and dependent on costly
technologies and specialist care,
 Provision of curative services through fragmented
process of care,
 Lack of continuity, poor quality and safety,
 Inefficient referral systems,
 Generates of exclusion and dissatisfaction.
Social Model of Care
This approach attempts to address the
broader influences on health (social, cultural,
environmental and economic factors) rather
than disease and injury. It is a community
approach to prevent diseases and illnesses.
Focus is on policies, education and health
promotion.
Social Determinants of Health
inequalities in early years,
levels of education,
employment status,
welfare and health systems,
level of income,
the places where men, women and children live,
the norms and values of society ,
attitudes concerning gender and ethnicity
– all contribute to inequities in health. They are known
as the social determinants of health.
People-Centered Model of Care
1.
2.
3.
4.
5.
People centered
Integrated
Comprehensive
Continuous
Life Course approach
Integrated Care
• Integrated care is an approach for people and communities
that seeks to identify and resolve gaps in care, or poor care
co-ordination, that leads to adverse impacts on care
experiences and care outcomes.
• Integrated care should not be solely regarded as a response
to managing medical problems, the principles extend to the
wider definition of promoting health and wellbeing.
• Integrated care is most effective when it is populationbased and takes into account the holistic needs of patients.
Disease-based approaches ultimately lead to new silos of
care.
Nick Goodwin, 2014.
Comprehensive Care
• Services and interventions that span the
spectrum of promotive, preventive, curative,
rehabilitative, palliative and social care in both
levels of services (First Level and Specialized
care), and are coherent with person’s life
course;
• Integration of Public Health and healthcare
delivery services.
Continuity of Care
is the degree to which a series of discrete
events in health care are experienced by
persons as coherent and interconnected and
addresses their health needs and preferences.
(User perspective).
Continuity of Care
Coordination mechanisms for:
• Sharing essential information for healthcare delivery
• Integrating care across levels and institutional boundaries
• Regulate access to different points of care in the network
INSTRUMENTS:
• Evidence Base Medicine (clinical guidelines and protocols)
• Electronic health records
• Referral mechanisms
• Innovations in service delivery modalities (home care, daysurgery, specialty clinics in support of the First Level of
Care, Telemedicine, etc.)
Health System Reform
Criteria and Principles
• Common goal: “the improvement of the health conditions
of the populations”.
• To promote equity in health conditions, access and
coverage of services and financing of services;
• To improve quality of care from the technical standpoint
and the user’s perspective;
• To increase the efficiency of health financing, and
allocation and management of resources;
• To ensure sustainability
• To promote social participation in planning, management,
delivery and evaluation of health services.
Challenges for the next decades
• From professional orientation to client
orientation
• From disease and intervention to health and
prevention
• From patient dependancy and satisfaction to
literacy, self management and co-creation
• From standardization to variation
• From quality systems and external control to
performance improvement and zero-tolerance
Concluding remarks
Some various issues
Technologies issues:
• Technology alone does not solve everything
and not everything can be done by regulation.
• Technology may deliver efficiencies in
healthcare, but not necessarily cost savings.
Data issues:
•
•
•
•
•
Collecting data strengthens the evidence base for political choices in healthcare.
Policymakers have the right to their opinion but not to their own version of
scientific facts.
Patients expect clinicians to have access to and use medical records to guide their
treatment. However, when asked if they are prepared to share their personal
health data, a significant proportion of patients refuse. This conundrum needs to
be solved.
Health data should be a public good, owned by the patients and health systems.
The future of data should not be left to digital giants.
Big data will help to drive change. Two new types of data – genomic and patientgenerated – will soon be more accurate and exceed the amount of data entered
into medical records by doctors. Cognitive computing capacity can analyse this
data and extract new insights. This is a future goldmine for health.
Building trust into the system is critical for people to feel confortable sharing their
health data. This requires authorisation mechanism, robust third party
authentication and smart regulation.
Regulation issues:
• Not everything that is „new“ is innovative or an
improvement. Remove regulatory barriers when it is safe,
and improves access for all.
• There is leadership and new thinking at EU level but
implementation is blocked by cultural differences and
regulatory barriers at national or local level.
• Regulators have a brief window of opportunity to manage
the changes rather than just responding to external
developments.
Individual/patient issues:
• The EU should do big, not small. Infrastructure needs to be
put in place at EU level, but individual consumers will drive
the revolution.
• Existing eHealth services show that patients trust digital
service provision. However, healthcare systems are not
designed for a business model that allows this trust to be
exploited. The current working models are largely for those
willing and able to pay for it outside the health system. Many
public and insurance systems won't pay for virtual
consultations, reinforcing the tradicional face-to-face model.
• Attention needs to be given to the human factor of changing
behaviours and mentalities.
Innovative issues:
• Public procurement tends to focus on the short term
issue of getting services for a cheaper price. A more
holistic view of the overall healthcare system and its
needs could prioritise innovation as a criterion for public
tenders.
• There are pockets of change or innovation in different
parts of Europe, but governments need to get better at
identifying them and bringing them back home as pilot
actions.
• Healthcare has to evolve from treating illness to
maintaining health. In terms of information
mamagement, this means starting to look forward using
digital tools for insights and patient engagement.
KEY MESSAGE
• There is no single best practice for HSR
(Health System Reform) in a changing Europe,
but in order to contribute to improvements in
population health, reforms should be
congruent with citizens’ values;
• contain mechanisms to protect the poor; and
strengthen the capacity of national and local
stakeholders to plan, administrate, regulate,
evaluate, and innovate.
Key Take Away Ideas
• There is a difference between integration of
services and integrated care.
• Integrated service delivery is a key strategy for the
attainment of Universal Access to Health and
Universal Health Coverage (Universal Health)
• Integrated care and Integrated Health Services
implementation tends to be more successful
where there is a commitment to the values and
principles of Primary Health Care
Four key conclusions emerge
• Social values become increasingly important as pressures on
healthcare systems intensify.
• Political will – to reflect social values while delivering effective
healthcare – is essential.
• Any renegotiation of the health social contract needs to be
consistent with the demands of political accountability in a
democratic society.
• There is unlikely to be a single solution to responding to
challenges in delivering healthcare costs; an integrated approach
that takes account of the broader context is essential.
LITERATURE
Holder R. Health Services and Access Unit, Department of Health Systems
and Services, July 28-30 2015, Belize
Friends of Europe., www.friendsofeurope.org, accessed: 14. November
2016.
The Future of Healthcare in Europe. London’s Global University, UCL
European Institute and UCL Grand Challenges, London, UK, 2015.
Pan American Health Organization
World Health Organization
Thank you !
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