sou · H0B333 · 2012-05-15 00:00:00 — Policy challenges and priorities Looking at expenditures, had been heavily hit by a steep economic depression in 1991 that led to a marked decline of total health expenditures in real terms and public expenditures as a share of total health expenditures. The share of total expenditures as a share of GDP remained relatively stable until 1995 but started to substantially decline thereafter. The decline in state funding was compensated with an increase in private funding through user charges and the abolition of tax deductions on expenses. The low per capita spending on health care in the midst 1990s and early 2000 compared to the other Nordic health care systems has thus been subject to on-going policy debate especially in the past decade. Overall per capita spending has substantially increased over the past 5 years, but there are substantial differences between muni- cipalities. Another problem is related to the small size of numerous municipalities and the small funding pools available to cover costly interventions. This has led to the creation of municipal federations and governmental equalization processes such as cross subsidies. Yet, the small size of the covered municipal population and major differences in catchment areas and geographical access has also led to concerns about equitable access, efficiency and quality of health and social services in particular since municipalities have pro- gressively opted to introduce user charges to cover health care expenditures. Large differences in purchasing power and capacity of municipalities to purchase care from the 21 hospital districts and private health and social services providers and the fact that smaller and remote municipalities simply lack the choice such as over accessible hospitals has further exacerbated the differences in play- ing fields of the municipalities. has also seen an emergence of parallel coverage and provider structures such as through the double coverage of em- ployees through their occupational health entitlements, and those through their entitlements as resident of a certain municipality. These have been exacerbated by problems in aligning the new municipalities competences with the countrys fundamental values of equity and universalism. The public/private mix in health care has not seen a major shift in policy priorities. Regarding financing, the mechanisms around multi channel financing have progressively led to an increased share of private funding sources over time. Private provision of primary care has been subsidised by the state with the objective to increase consumers choice on their care providers. Municipalities have in- creasingly experimented with outsourcing provision in primary care and it is increasingly common for municipalities to contract specific services segments from the private sector, for instance certain low risk operations such as cataract surgery. Common is the voucher system whereby patients are given a voucher to pur- chase care from the providers of their choice, and choice of a private provider is likely to yield higher user charges. Yet, although there is a role for the private sector in the Finnish health care sys- tem, private care models have evolved in an incremental and some- what experimental way as an alternative towards public integrated provider structures partly to tackle shortages in public sector staff, and partly to test out efficiency savings and they are not developed as an explicit strategic priority of the Finnish health care system to date. An explicit objective of a trans-governmental productivity programme in 2006 to 2007 was to diminish administrative costs of the governmental apparatus by reducing the number of posts simply by not renewing posts that became vacant through retire- ments. The reform was implemented across all governmental legi- slative and executive services. It should be note that in general, decentralizing responsibilities in health care is widely accepted in as the population is dispersed and thus values local decision-making and accountability structures – so that any reverse direction is politically difficult to implement. Major changes in are usually achieved through law. One of the most visible tools to address concerns related with unequal access, waiting times, availability of human resources and differences in standards of care was the 2001 government initiated project to ensure the future of health care. This project resulted in an agreement between the national government to increase the level of state subsidies to municipalities and in turn for munici- palities to work towards a number of structural changes, and a set of new standards in care (Vuorenkovski et al. The agree- ment also resulted in waiting time limits on 270 diagnostic catego- ries in hospital and primary care regulated by the Primary Health Care Act and Act on Specialized Care implemented that came into force in 2005. Where the government holds responsibilities such as in the pharmaceutical sector, it has also been able to effectively tackle fast growing expenditures through introduction of a reference price system to regulate prescriptions of generics against the fierce oppo- sition of pharmaceutical companies. The reconfiguration of municipalities has been a major instru- ment to counteract the negative consequences of decentralization. In 2008, more than of municipalities had fewer than 10.000 inhabitants and had fewer than 2.000, and thus many muni- cipalities were too small to secure sufficient skill mix, resources and infrastructure for providing services. With the previous govern- ment, the number of municipalities was substantially reduced from 415 in 2008 to 336 in 2011, covering a minimum of about 20.000 people. This process has been fairly smooth, partly due to the support of the Party that has particularly strong positions at the rural municipal levels. The most recent Health Act of 2011 introduces patient choice on the primary care centre and the family physician and nurse, and on public hospital for treatment. The above mentioned governmental productivity program has sub- stantially reduced administrative costs of the central government and at regional level, but municipalities have in turn had to strengthen In addition, the downsizing of legislative and executive capacity at central government level at the same time was accompanied by a substantial upheaval of capacity at the level of institutions operating at arm length of government. For instance, whilst in 2005, the had a small team of core staff of about 70, the merger of lic Health and created a core staff of around 1.000 people. Institutional changes over time also created upheavals in institutional governance arrangements at national level. For instance, the remit of a national institute respon- sible for professional regulation was first extended to social policy, then to certain areas of public health, before these responsibilities were then shifted back to the level of the provinces. is another example of a national institution that struggles with an explicit decision to geographically move it away from the centre. The decision to relocate its headquarters from to in three stages up to 2014 makes it more com- plicated for the institution to operate at arms length from govern- ment and more importantly to recruit qualified professional staff. The current system that leaves municipalities in charge with a high degree of autonomy is still associated with low costs com- pared to other European countries within a similar income spec- trum and high satisfaction of the Fins with their services. The stronger remit of the municipalities has however created tensions in the past around the limitations on central subsidies for the municipalities and the centrally defined obligations. Municipal authorities have repeatedly called for higher levels of subsidies in order to fulfil these obligations in the past. This has in effect in- creased the role of the in steering the system. The weakening of the steering role of the has also left an empty space towards a strategic national leadership role for health policy. Overall municipal investments, human resources recruitments, and expenditures have heavily focused on the secon- dary and tertiary care sector as well as the occupational health sec- tor which has tended to promote private provider and more spe- cialist care setting. The municipalities autonomy in steering the provision of care meant that the state was unable to effectively intervene in this development. For instance, the initiative of the central government in 2005 to introduce regulations for providing specific maternal and child care services within the municipal pri- mary health centres took more than three years of negotiation between the central government, the municipalities and the doctors. Overall, the heavy focus on specialist care has compromised reputation as a leader of primary care in Europe. The waiting time limit is considered a major achievement that has brought down waiting lists and times substantially in hospital and outpatient specialist care. In primary care the policy has been less successful owing to substantial remaining challenges in recruit- ing primary care workforce. The degree of decentralisation in the Finnish health care system has arguably been higher than in most other European countries and there have been some commentators pointing out that the problems involved in the high degree of decentralization such as inequalities in financing, access and quality of care may have out- weighed the advantages associated with local responsiveness of policies to the health and social needs and preferences of the people, accountability and local participation. Yet, according to the pendulum principle, the trend toward decentralization is currently reversed partly to address some of the challenges of decentralized admini- stration. For instance the governmental programme for the restruc- of municipalities and services decreased the number of municipalities. The national government has also fostered increased cooperation between municipalities and has reduced the number of central hospital districts from 22 to 18, and has introduced national criteria for waiting time limits. Further central level regulation is expected to focus on legislation on care for the elderly and primary care, in which legislation has been rather piecemeal. The election has changed the political landscape in , with the National Coalition Party, and the Social Demo- crats turning out as main players in the six-party-coalition govern- ment. This government has announced a substantial further merger of municipalities towards an average population size of 100.000, which would reduce the number of municipalities from 336 to about 53. It is not yet clear how this reform would be implemented and whether it would be accompanied by further principle changes in the governance arrangements. For now, the strongest party in oppo- sition, the Centre Party, has posed vivid resistance against this reform. Governance model and recent changes The French system is characterized by strong state regulation. Whilst traditionally planning and regulation has involved negotia- tions between the representatives of the providers, social health insurance and the state, the role of the state in planning has in- creased over the past two decades. The system remained fairly stable up to the 1990s but reforms in the last two decades have attempted to devolve planning responsibilities to the regions. 1996 reform (called the reform according to the Prime Minister at the time) empowered the 26 regions to undertake hos- pital planning. As a consequence, several regional institutions were created to represent the main stakeholders. These included repre- sentative bodies of the social health insurance funds, represen- tatives of the health professionals and public health actors. As a result, the regional planning work became somewhat dominated by the partial interests of individual actors. The 2009 Hospital, Patients, Health and Territories Act (loi hôpital patients, santé et territories; HPST) tried to tackle this by merging the majority of these actors into 26 regional health authorities (agence régionale de santé; ARS) leading to more integrated institutions, cutting across the boun- daries of health care, public health, and social care. As in many other European countries, rising costs have made it rather difficult to deliver on the principal objectives of the French system that are listed in the 2004 Reform Act and include: and equal coverage, equitable access to care, fairness in finance; and continuity, coordination and effectiveness of care (Chevreul et al. The health system in is amongst the five top nations in the world in terms of per capita expenditures and health expenditures as a share of GDP. This level of expenditures becomes problematic in times of troubled economic performance and growing public deficits. One important priority justifying strong central level steward- ship is fairness in financial contributions to care, and minimizing the risk of financially grounded exclusion from care such as through granting free access to voluntary health insurance or providing vouchers to low income patients to cover user charges. The policy objectives behind the introduction of regional health authorities were for once to simplify and improve the regional governance, ensure policy coherence and better tailor services port- folios to population health needs as well as facilitate the continuity between the different sectors of care especially to meet the increasing demand for long term care and to increase the power of the regions to tackle inequalities in health care access in their catchment areas. The 2004 Public Health Act was introduced with similar inten- tions to improve coordination and consistency in public health policies yet at national level by putting forward 100 health prio- rities. The priorities were translated into targets and indicators for each social security branch in the so-called quality and efficiency programmes. The programmes in the health insurance branch are aiming to balance access to health insurance benefits, ensure adequacy of health insurance coverage to meet population health needs, provide efficiency in the provision of insurance benefits and work towards financial sustainability (Chevreul et al. They include a programme 1 on equal access to care with targets to reduce physicians extra ; a programme 2 of five preventative health targets; and a programme 3 to enhance quality of care with targets for improving referrals from a GP, reducing waiting times, improving availability of primary care on a 24 hour basis, improve hospital acquired infections, increase the number of accredited health care institutions and enhance professional appraisal. Programme 4 aims at improving efficiency and control expenditure with targets for instance on drug prescriptions and use; sick leave compen- sation; and elective procedures performed on an outpatient setting. Policy priorities in hospital care have been mostly related to increasing productivity and efficiency in hospital care. The 2009 HPST Act reformed the governance of public hospitals by allowing more flexibility in the management of public hospitals. Compe- tition amongst public and private hospitals was to be promoted by introducing a common funding structure by adopting similar DRG tariffs by 2012. Tools and debates around them In spite of a stronger role of regions in previous years, the , and the government and parliament remain the most powerful regulatory and policy-making institutions and this role has further strengthened in recent years. Following the 1996 reform, the parliament was mandated to approve the national ceiling of the annual health insurance expenditures and the revenue side of the budget. The 1999 Health Coverage Act is another central- level steering device that has regulated basically free access to volun- tary health insurance for low income groups through providing free voluntary insurance or alternatively a voucher system that removes the requirements for out of pocket payments. Act in 2000 transferred responsi- bility for hospital policy from social health insurance to the state. Reform Act and the Public Health Act further- more changed the governance of the system in 2004 by increasing the role of the parliament in setting the above mentioned health priorities and establishing national management of social health insurance. The parliament also acquired a new role with its which is activated when the social security deficit reaches a predefined threshold. After 2004, two categories of care were implemented with different tariff structures. In addition, stricter control on tariffs was enforced. Although tariffs are negotiated between providers and social health insurance representatives, they are subject for final approval by the . The re- form furthermore formalized a gatekeeping system with financial disincentives for direct access of services without consulting with their preferred doctor. Another area that is increasingly determined by national policy is quality of care with a plethora of tools. National agencies have been developing mandatory practice guidelines and good practice commitments have emerged between collective representatives of health professionals and social health insurance. Sanction fines for non-compliers initially accompanied these commitments but there is now a trend towards establishing a pay for performance scheme for individual doctors based on good practice targets: Individual practice contracts for practice improvements were introduced in . The contract uses a pay-for-performance incentive to achieve efficiency targets in primary care, of which the prescription of generics and of low-cost statins received much public attention (Chevreul et al. A good half of all free practicing doctors are eligible for receiving additional payments for achieving targets. A national policy requires hospitals to undergo certification every 4 years and all health professionals have to provide proofs for regular continuous training. The strong health policy role of the government has triggered the of high-level advisory bodies in recent years such as (Haut comité pour lavenir de lassurance maladie (later changed to the Haut conseil pour lavenir de lassurance maladie; HCAAM)); (Haut conseil de la santé publique; HCSP); and the . In 2004, the National Health Authority was established to support quality and equal access to care independent from government. The Authority provides assessments on drugs, devices and procedures, accredits health care institutions, certifies professionals and pub- lishes clinical practice guidelines. The Authority reports to govern- ment and parliament. The 2009 HPST Act enacted the merger of health care, public health and social health insurance funds at the regional level with the objective to identify health needs and establish priorities at the local level with the major stakeholders including hospitals, self- employed health professionals, public health decision-makers, patients representatives, and representatives of the state and social health insurance (Chevreul et al. The law was implemented in 2010 by establishing 26 regional health authorities with the man- date to coordinate outpatient ambulatory care, hospital care and long term care for the elderly and the disabled within their catch- ment area. They are responsible for developing strategic regional health plans that spell out criteria and targets for the provision of care. The strategic health plans are based on epidemiological and demographic profiles of the catchment population, and indictors for the utilization of care. These plans are designed to provide the framework for any services planning and tendering conducted at regional level. Regional health authorities can rationalise, they for instance have now the power to close or merge hospitals. As part of their mandate, regional health authorities have also more in- fluence on workforce planning and distribution. They can set out legal provisions for the transfer of tasks between health professio- nals, can set their numerous clausus for school admission in accordance to their current and projected regional health needs, and can optimize the distribution of health professionals by pro- financial incentives for professionals to serve in under-supplied areas. The regional health authorities are now in the driving seat for any service related planning. The degree of power given to the new regional health autho- rities and especially their director in the 2009 HPST was subject to some controversies between the national ministry of health and the social health insurance funds. consequently advised the government to limit the remit of regional health authorities towards implementing nationally defined priorities but these proposals were rejected. Instead amendments to the original plans were made to concretize the terms of refe- rences of the regional health authorities and their directors, to in- crease mechanisms of accountability, and to allow others than civil servants to apply for the position of the regional health director (Or, 2009). A key concern of those that remained sceptical to the reform is that the appointment of a regional health director as well as a public hospital requires the prior approval of the ministry of health and that hospital and regional directors are accountable to the state so that regional autonomy in reality might be limited and any regional decision making can potentially be overruled or under- mined by the central authorities (Or, 2009). The French population enjoys good health with high life expectancy and longevity, low infant mortality, and comparatively low preva- lence of cardiovascular diseases and obesity. Most of the French are relatively satisfied with the system. The introduction of the gatekeeping system did not result in major changes for several reasons. One is that the gatekeeping reflected existing patterns of utilization of transferal through a preferred doctor. It has also been simple to change the preferred doctor. Another reason is that some essential specialities were ex- cluded from the transferral scheme (dermatology, gynaecology, paediatrics, ophthalmology and psychiatry). And in reality access outside the referral scheme has been granted, basically without sanctioning consequences (Chevreul et al. The CMU scheme has not yet entirely achieved its objectives to remove financial barriers to access of care since some physicians refuse patients under the CMU scheme partly because they have no possibility for extra above the tariffs reimbursed by the insurance companies. There is also concern that the deductibles on consultation, ancillary care, transportation, and drug problems will increase access problems. Overall, The reforms aimed at tack- ling inequality in access to care have probably not yet yielded the expected results. For instance in 2006, in 2006 of the popu- lation aged 18–64 years were reported having forgone health care in the last 12 months for financial reasons, while this share amounted to in 2008 (Allonier et al. 2008, 2010). The setting up of in 2004 and new statistical monitoring procedures for the health insurance expenditure budget has started to show an effect since 2003 when the size of the budget overrun has started to decrease up to 2007. The system has undergone a fair amount of governance reforms in recent years but the has retained substantial control over the health system.