sou · H0B333 · 2012-05-15 00:00:00 — The result is that in spite of millions of Euros of financial investment, no assessment of the entire SNS perfor- mance, whatever the level of disaggregation, is currently feasible. In short, the Spanish devolution process wasnt carefully planned, but rather was a sequence of unsolved clashes between the centre and the periphery (regions) on claims of historical rights, conflicting financing figures and political gambling. By design, as indicated, the MSPSI held the responsibility to set what is known as the bases and the general coordination of the health system as well as the com- petences of foreign relationships in health and pharmaceutical legislation (public reimbursement and price setting of drugs). Regions had in turn competences on health policy formulation and imple- mentation as well as planning and management of personal and population health services. In practice, however, determining the scope of the respective competences was more difficult than fore- seen and frequent clarifications had to be required, including con- sultations to the Constitutional Court, since 1983 (Beltrán, 2007). In recent years the MSPSI has only proposed vague ideas and suggestions at the , often without much previous study. For example, a proposal by the then Minister that final-year students of Family Medicine could be exceptionally allowed to operate as public health specialists as a transitory remedy against lack of staff in the specialty was simply rejected by the CAs (Diario Médico, 2008). Regional governments sometimes fail to report on certain issues, or even refuse to adhere to using homo- geneous criteria for reporting (as in the case of waiting lists and waiting times) (El Mundo, 2011). Perhaps the idea of a National Healthcare Agreement (Pacto por la Sanidad) finding common solutions to critical pending issues and involving all regions and political parties which floated at the beginning of the current parliamentary period is the best proof of the hopes and limitations of the current state of mind of the . Originally proposed in 2008 by the above- mentioned Minister , the appeal included as pending issues not less than human resources policy, common services, budget sustainability, common health policies, quality and innovation and prevention of drug addiction. When in the context of the financial crisis, the next Minister of Health and Social Policy, Jimenez, was appointed in she embraced the initiative, establishing six working committees whose membership included other stakeholders, including patient groups. Her latest statement on the matter in suggested however that any agreement would not be signed before 2013. a new Minister was appointed (third one in three years) with a rather non-health-profile. The economic and political crisis has made increasingly visible tensions and challenges that were always there, raising clashes between parties and between regions in a context of polarization bordering filibusterism. For example, three months ago regional ministers from the opposition refused en masse to attend meetings of the Inter-territorial Commission. Yet this was in turn a response to the arguable initiative by the Minister of Health calling on the Inter-territorial Commission, to approve major changes two days before regional elections would massively change the countrys poli- tical landscape – and with it the composition of the Commission, literally (this practice had already been applied years ago to the then Conservative-led government by regional ministers of the Socialist party currently in government). Some high officials of the MSPSI (for example, the General of the Ministry ) have publicly blamed the tensions on a lack of political will in the regions, to whom he was publicly asking for more institutional loyalty (Martínez Olmos, Beyond taking position in the political debate (mostly natio- nalists versus centralizers), entire segments of the Spanish society are advocating for the suppression of central departments, including the Ministries of Health and Education, etc, considered redundant as their same function is being done at the regional level. Others are calling in response for a substantial reduction to the degree of autonomy regional governments should have in the future. Governance model and recent changes The governance arrangements in the Swiss health care system are based on three traditional constitutional features. The first is a federal structure with a strong focus of decision making by cantons and a complex organization of powers and responsibilities between the cantons and the national government. The second key charac- teristic is a tradition of direct democracy through popular votes and referendums and governance through consensus. And the third is a growing reliance on a regulated market of competing private health insurers and providers that limits the role of the government authorities to setting the financial and regulatory rules to ensure market performance (/WHO, 2011). At the same time, a number of new laws including the LAMal – the basic health in- surance legislation of 1994 that made health insurance mandatory – has strengthened the role of the confederation. The draft law on disease prevention and the national health project are prominent and more recent national developments in this direction. There are yet a number of strategically underdeveloped areas and overall, the federal policy making institutions have as yet to live up to the new requirements and build capacity for their new leadership role. The different parallel principles have given rise to a tension between defenders of market approaches and those calling for more state regulation (/WHO, 2011). Cantons are under pressure to meet expectations and results towards national objectives on cost containment, efficiency, and quality of care and are increasingly willing towards working for national targets such as on the package of nationally set indicators for hospital care which have been elaborated and adopted in 2011. The growing efforts of the for Public Health in assuming more regulatory and policy-making control in some areas have also triggered improvements in the collaboration between can- tons. For instance for the planning of hospital investments in 2012, cantons have recently provided a joint list of funding requests. The most important policy priorities behind the recent dynamics in governance changes are those related to the traditional design of the system such as reemphasis on the instruments for direct demo- cratic control, accountability and responsiveness to local needs. Enhancing consumer choice on insurers and health care providers and increasing their participation in health care provision is one of the main objectives behind enhancing rights of patients for instance to seek care outside their cantons. Policy motives behind the re- naissance of cantons is the view that the strong focus on cantons as the most important tier of regulatory, fiscal and managerial autho- rity over health care has enabled a fair amount of experimentation and innovation in in policy decision-making in : fastest progress has for instance been experienced in areas that have been piloted in one or few cantons such as drug substitution or alcohol policy. Yet, the need for more policy coherency has at the same time driven consensus based processes, such as for instance the agreement within the Conference of cantonal health directors to common planning of highly specialised health services. The call to- wards enhanced quality of care and a more uniform strategic frame has also substantiated the developments of standards towards for health promotion and disease prevention at national scale. At institutional level, there is a renewed emphasis on instruments of a regulated market, for instance managed and integrated care models and drivers for competition between health insurers and between health care providers. The recent interruption of the peak organization of the health insurers has discontinued the monopoly of health insurers. The re-organization of some major insurers is likely but these will also likely promote individual contractual nego- tiations over collective one size fits all solutions, which have allowed more flexibility in pricing. A new law for hospital financing putting forward payment per case schemes has been adopted that aims at improving transparency of pricing negotiations and redu- cing potential conflicts between insurers and providers. Another draft legislation on health insurance surveillance is currently under consideration that is aimed at protecting the insured through in- creased control of the state such as on insurers practices to ensure coverage with potential sanctions. The new draft legislation permits national goals on disease pre- vention to be formulated by the federal government in collaboration with the cantons and nongovernmental organizations. Some scepti- cism has been expressed towards the intentional nature and towards the diversity in cantonal capacity and infrastructure to meet the national targets (/WHO, 2011). Priority setting and health technology assessment is not well established at central level and leaves scope for improvement. Only a fraction of services covered under health insurance are evaluated in some form (/WHO, 2011). doctors have so far dissented with a stronger central governance role towards health technology assessment but a recent development is the establish- ment of by the conference of cantonal health directors (CDS), the association of Swiss physicians and Sciences. provides assess- ments and policy recommendations for pharmaceutical and interventions. is seen as an initial step towards the permanent institution of a privately operated health technology assessment institute at national scale but the role of the national government in this initiative remains uncertain. The strong focus on cantons in combination with direct democracy instruments have enabled immediate democratic control, flexibility of cantons to respond to local needs, and an innovative environ- ment through providing the scope for experimentation. Enhanced consumer choice on insurers in recent years has started to show an effect: approximately of insured have changed their insurer in recent years, albeit the changers are mostly made up of young and healthy individuals (/WHO, 2011). The challenge associated to the high degree of decentralization has been policy incoherency between cantons; conflicting incen- tives for cantons for instance for cost control as the regulator and owner of hospitals; a heavy focus on curative care with a backlog of disease prevention patterns; and lack of strategic oversight and poor national level information on quality and performance (/WHO, 2011). In addition, the presence of direct demo- cracy elements contesting legislation and strong lobbies of doctors, insurers and the pharmaceutical industry in parliament that can influence legislation might have slowed down the pace of reform. Governance arrangements have followed a complicated division of powers and responsibilities between the cantons, the most important decision making tier, and the national government. The most recent developments exhibit dynamics towards all three of the possible options for changing governance arrangements: First a renaissance of cantons as strongest policy decision-making tier with a subsidiary supporting role of the state when the cantons fail to resolve issues that are critical to the fundamental economic or welfare concerns of the country. The development towards collective inter-cantonal strategy and policy development, dialogues and platforms as showcased in the areas of planning highly spe- cialist health care services and a joint list of hospital investments of cantons for investment planning in 2012. Second, at the same time, the emergence of a stronger central governance role can be obser- ved in the domains of regulating and policy making for quality of care standards, health insurance surveillance and disease preven- tion. And third, there is also a notable reemphasis of governance arrangements in managing, organizing, commissioning and pro- care through the self-governing actors of the regulated market partly on the objective to enhance patient and consumer choices and maintain the liberal environment for health insurance and health care provision with a view to position the health care sector towards one of the most efficient, productive and innovative sectors of the economy. Overall, the speed of dynamics in gover- ning care arrangements has accelerated in 2010 and 2011 compared to the previous years. Yet, recent changes in governance arrange- ments do not suggest a total shift of responsibilities but rather more collaboration. 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Viktiga förutsättningar är t.ex. utvecklingen i vården och det över- gripande ramverket som anger villkoren för hälso- och sjukvårdens styrning. I denna rapport tas det kommunala självstyret för givet. Det inne- bär att ansvaret för att en god hälso- och sjukvård tillhandahålls individer på lika villkor i första hand antas ligga hos landsting/regioner och kommuner. De statliga myndigheternas inflytande över vården blir därmed i första hand indirekt genom att ange normer och ramar för verksamheten, ge kunskapsstöd som underlag för lokala beslut, följa upp och utvärdera, samt utöva ansvarsutkrävande re- 1 , , , Tandvårds- och läkemedelsför- månsverket (TLV), Myndigheten för vårdanalys, , () samt är de viktigaste. För- och nackdelar med denna förutsättning disku- teras inte generellt i rapporten. Däremot diskuteras några poten- tiella problem med denna övergripande styrform som måste beak- tas i den statliga styrningen, bl.a. risken för olika former av sup- optimeringar. En annan viktig förutsättning för statens styrning är utveck- lingen i vården avseende medicinsk teknologi. Beroende på vilken teknologi som finns tillgänglig och hur den utnyttjas påverkas hur vården bedrivs och därmed förutsättningarna för olika typer av stat- liga insatser. I rapporten diskuteras i första hand konsekvenser till följd av ökad specialisering, mer öppen och vård och bättre förutsättningar för uppföljning av vårdens kvalitet och resul- tat. Dessa utvecklingslinjer kan förväntas gälla också . En ytterligare viktig förutsättning för statens styrning är hur styrningen av hälso- och sjukvården utvecklats över tiden, både på nationell nivå och bland landsting/regioner och kommuner. Detta diskuteras i rapporten utifrån en genomgång av några centrala för- ändringar och slutsatsen att styrning mot resultat, kvalitet och effektivitet blivit allt viktigare. För att diskutera statlig styrning finns behov en mera allmän modell över styrningens olika komponenter. Ett förslag på en enkel sådan modell som skiljer mellan prioriteringar och normer, uppfölj- ning respektive ansvarsutkrävande presenteras. diskuteras alternativ för statliga myndigheters insatser inom hälso- och sjuk- vårdsområdet med hjälp av denna modell och utifrån de förutsätt- ningar som analyserats. Diskussionen delas upp i två delar. I en första del diskuteras vad statliga myndigheterna som kollektiv bör göra. I en andra del diskuteras hur ansvaret kan delas upp och konsekven- serna för nuvarande myndighetsstruktur. 2.Det kommunala självstyret och några konsekvenser för den övergripande styrningen Ett fortsatt kommunalt självstyre antas vara en given förutsättning i denna PM. Just därför kan det vara på sin plats att kortfattat peka på några viktiga konsekvenser av det kommunala självstyret för den övergripande styrningen. En första viktig konsekvens blir naturligtvis att staten har be- gränsade möjligheter att påverka verksamheten, åtminstone på kort sikt. På lång sikt har staten vilka möjligheter till påverkan som helst, men då krävs förändringar i lagtexten vilket i sin tur kräver majo- ritet i . På kort sikt måste staten försöka påverka på annat sätt, t.ex. genom dialog och överenskommelse med landsting/regioner och kommuner om hur riktade statsbidrag kan användas. Denna styr- form används allt mer. Det säger sig självt att styrning genom dia- log blir mer effektiv om den ansluter till frågor som ändå drivs av landsting och kommuner. Staten kan på så sätt driva på frågor som ändå är aktuella, men det blir svårt att driva igenom förändringar som inte gillas av landsting och kommuner. Sådana åtgärder kräver lagförändring. Det är också lättare att genomföra förändringar som baseras på dialog bland de 21 landstingen än de 290 kommunerna.