sou · H0B333 · 2012-05-15 00:00:00 — Often these tools comprised legal means to change the scope of responsibilities of a certain admini- strative or governmental decision-making tier, or the of new institutions. In the impact section we tried to modestly assess whether the changing government arrangements have yielded the effects that the reform was intended to have. We also considered unforeseen effects of the reforms and constraints in their implementation. Each country section also has a short introductory paragraph on the basic governance model and a description of the recent changes, as well as a concluding section providing an outlook for possible future options and likely directions in governing the health system. PART I COMPARATIVE GOVERNANCE THEMES AND ISSUES Health sector governance involves a complicated mix of activities, that run concurrently, and at multiple different levels of the fun- ding and service delivery system. These activities can stretch from strategic (legislation) to mechanical (reporting financial or clinical data), and may involve a variety of institutions and/or health system levels in any one particular process (eg regulating physician behaviour). Further, these activities typically have political, finan- cial, clinical, institutional, professional, legal and economic dimen- sions, often at the same time. While governance traditionally had been an intra-health-system activity, in the last several decades a variety of outside actors – most notably patients and citizens – have also been drawn into the mix. In summary, then, it is a com- plex area of responsibility that requires a complex analytic perspec- tive (Saltman, and DuBois, 2011). Given this broad perspective, the national government should be viewed as a key but not an exclusive actor in the design and implementation of governance measures. While some areas of gover- nance – for example certain regulatory and reporting requirements – naturally fall within the purview of the national government, other regulatory roles (for example, professional behaviour) and institutional responsibilities (for example, within semi-autonomous public and/or privately operated hospitals) may properly fall to non-national government and indeed to completely non-govern- mental agencies, depending upon the construction of the health system and its operating mandate. This complicated mosaic of responsibilities and actors suggests that strategies and measures to change the role specifically of the national government in the behaviour and performance of specific sub-sectors of the health system (for example, highly specialized hospital services) should not be conceived or introduced in isola- tion. Rather, these measures need to be understood within the broader context that they take place within, and which can accele- rate or retard their ability to achieve their stated objectives. As experienced national regulators know well, professionals believe (and not always inappropriately) that substantial clinical auto- nomy – eg separateness from political and politician-based decision- making – is essential to providing and maintaining a high standard of care (Mechanic, 2000). Further, as organizational socio- logists have long documented (, 1938; Roethlesberger, 1941; , 1948; Crozier, 1972), efforts to impose external authority on technically based employees can lead to a variety of unexpected, sometimes perverse organizational outcomes. A further factor in this governance mix is the complex character of regulatory interventions by national governments in health sys- tems where operational decision-making is decentralized to regional bodies (as in ) or delegated to private non-for-profit and/or for-profit actors (as for example in ). Regulation in these multi-actor contexts is considerably more difficult than in a top-down command and control state-run mode of service funding and delivery (Kettl, 1993). Moreover, if a contract-based, market competitive model is adopted, regulation takes on further com- plexity, becoming sub-divided into regulatory measures that pro- mote those forms of competitive behaviour that are seen to be positive to achieving political objectives (eg raising quality of care), as against regulatory measures that restrain competitive behaviour that is seen to be negative in achieving political objectives (eg ad- verse selection of insurees or patients) (Saltman, Busse and Mossialos, 2002). A key task of national government thus becomes designing regulation to encourage good competition and to restrain bad competition – a central task if a central government is to re-design and modernize health sector governance. The brief country reviews in Part II of this report were undertaken to examine recent changes in the mix or balance of decision- making authority between national government, on the one hand, and either regional and/or local government on the one hand, or private not-for-profit or (in The ) private for-profit actors, on the other hand. The types of measures that were adopted can involve either formal transfer of responsibility between levels of government – which involve major structural changes in how government deals with health care – or they can involve a growing variety of non-structural efforts to create either better coordination among the regional governments (; ); better infor- mation flows between the regional and national governmental levels which give the national government a better view of ongoing activities in the health sector (, also ); or broader insti- tutional cooperation between public sector and non-for-profit pri- vate sector health actors (for Assessment). The results from these country reviews provide a useful snapshot of the type and character of changes underway in a variety of different countries, and also provide a sense of the types of governance measures that are being introduced in the face of a relatively well-defined set of common health sector challenges. The central theme that emerges from these country reviews is the extent of recent and/or ongoing efforts by national govern- ments to increase their decision-making leverage over important financial and/or clinical aspects of the health system (Saltman, 2008). These efforts can be both structural (eg changing the formal institutional responsibilities of national and regional and/or muni- cipal government) as well as non-structural (regulation and/or negotiation based) in character. These centralizing efforts reflect pressures on central government to achieve better financial (efficiency) and clinical outcomes. While diffuse, the sources of these pressures include higher patient expectations for care quality, tied to internet-driven awareness of different treatment options, the impact of IT based collection of financial and clinical data, and what has been called the blame factor: national politicians are held responsible by citizens if health sector performance appears sluggish, bureaucratic, and/or clinically inadequate. The country studies in Part II document the degree to which this broad centralizing trend continues to be observed in social health insurance based health systems (, , Switzer- land, also ) as well as in tax-funded health systems (, , , ). These efforts have taken a number of different, often overlapping forms, some of which involve direct re-centralization of decision-making authority, some involve establishing new national agencies that centralize previously un-coordinated areas of authority (for example dealing with quality of care measures), some involve new regulatory interventions that mandate certain changes from non-state actors (regional health administrations, private sector insurers and/or providers), and some of which are negotiated agreements with these regional govern- ments and/or also non-profit private actors such as national associations. Among formal structural measures to increase the national govern- ments authority has been national legislation that does the following: a)Transfers legal authority to national government over health system fund-raising and fund-distribution from regional govern- ments in tax-funded systems () or from private not- for-profit but statutorily responsible sickness funds in a social health insurance system (, ). b)Transfers legal ownership to state of major provider institutions (eg hospitals), shifting them to national control although with a new regional form of day-to-day operational responsibility (, ). c)Establishes new national agencies with mandatory authority over emerging areas of health system importance such as quality of care (, , ) or primary and/or preven- tive services (, ). d)Consolidate the number and/or responsibilities of regional/muni- cipal government bodies (, , , , ) It should be noted that not all structural reforms have been in the direction of centralizing more authority in the national govern- ment. Although this has been the predominant trend, there have also been several structural (legislative) measures that have shifted elements of health care decision-making downwards, either to regional governments (in 2010 of regional authorities) or to municipal governments (delegation of approximately of health resources to municipal governments, to be used in part to contract for preventive health services with private primary care physicians). Thus in some countries there has been a mix of structural measures, shifting some types of authority upwards but also sending certain types of authority (often tied to prevention and/or public health) to lower level and/or municipal governments. Similar strengthening of non-state actors – in this case private not-for-profit and for-profit () and/or corporatist () bodies – can be seen in social health in- surance countries in the continuing consolidation of health insurers. Non-structural measures to increase the national governments authority in the health sector have been both regulatory and inter- governmentally negotiated in character. In both instances, no legal boundaries were changed – there was no formal re-structuring of inter-governmental relationships. Thus the role of the national government was strengthened by adopting strategies that could be implemented inside the existing structure of formal institutions and the official allocation of ownership and operating roles of national, regional, and local governments. This has the political ad- vantage of being less cumbersome and time-consuming to imple- ment, as well as raising fewer (although certainly not no) political complaints from other levels of government. New regulatory measures that have strengthened the hand of the central government in the financing and production of health services have included: a)program of 100 priorities in 4 areas (access, prevention, quality, efficiency) in its 2004 Public Health Act. b)2009 Act to promote competition between public and private hospitals. c)new system of monitoring professional boards. d)adoption of a broad series of new regulatory measures including external commissioners to monitor the financial performance of regional governments. e)proposed effort to impose one national set of prices for all regionally delivered hospital, community and public health services. f)strong regime of four national agencies established to regulate non-public health insurance and health provider markets. g)proposed strengthening of Monitor to expand its regulatory activities beyond hospital trusts to include private hospitals as well as primary care practices. Negotiated compacts between national and regional governments and/or other private non-profit actors have a mixed record. In some countries they have worked out largely as anticipated (Switzer- land). In other countries, these negotiated arrangements between the national government and the regional governments have been largely honoured in the breech. Among instances of negotiated inter-governmental arrangements are the following: a)national goals on disease prevention are to be established by the federal government in collaboration with the cantons and non-governmental organizations. b)cantons have agreed to common planning of highly specialized health services. c)of a , organized by the conference of cantonal directors, the association of Swiss physicians and , which will serve as an initial step toward a private health technology assessment insti- tute. d), set up by the 2003 Cohesion and Quality Act, through which the national government hoped (incorrectly) to encourage the 17 autonomous regions to pro- vide quality and safety related data to the national government so as to enable it to monitor and evaluate regionally delivered health care services. e)national solidarity fund, intended to provide cross-subsidies between well-off and less-well-off regions to ensure equity of access (which never generated actual transfers). f)national health plan, agreed between the national and regional governments. g)proposed local planning processes, to be negotiated between National and local commissioning boards. h)Medicare locals, an integrated local planning unit intended to better collaboration among 100–300 professionals of different disciplines. Several additional issues emerge from a close reading of recent country experiences presented in Part II. These reflect broader questions about the overall focus and direction of current efforts to strengthen the role of national governance in European health systems, and remain questions without any clear answers at this stage in the re- form process. a)Are new national agencies a cost-effective solution? A number of countries have turned to new national government infrastructure as part of their solution to regulatory gaps in their health care systems. In some instances (, ), this new infra-structure has replaced previous national agencies, often incorporating elements from those agencies. In other in- stances (), these new agencies are being built out in addition to previous, sometimes overlapping national and/or regional government authorities. When and under what institutional circumstances are new national agencies a good idea? When are they likely to be ineffective and/or counter-productive? b)How successful will new national efforts to align sub-national actors be? Recent experience in several countries with strong regional responsibility in the health sector (, , ) have found it quite difficult and slow-going to shift the existing balance of decision-making control more toward natio- nal goals and objectives for their health care systems. Similarly strong resistance can also be observed in various professional, labor union, and other staff organizations. Even when these national governments have full authority over the financing of their health sector (, ), these governments have not been able to affect health sector outcomes as they would like. What mix of structural and non-structural tools is most likely to produce the types of organizational and behavioural change that national governments are seeking to create? c)How can national governments streamline the decision-making procedures within regional and municipal governments? In a number of countries with decentralized responsibility for day- to-day operating decisions for the health sector, the sub-national governments are themselves highly bureaucratic and politicized (for example, and ). National government goals to improve the quality, safety, and cost-effectiveness of service delivery may be difficult to achieve if regional governments are not modernized and managerially efficient. Imposing new gover- nance standards from the center, however, is highly fraught politically, and unlikely to be considered except by the strongest of national governments. It is also likely to alienate key pro- fessional and patient groups, who rely upon their ability to in- fluence local government decision-making. What strategy can ensure that new national regulatory initiatives are not dissipated by more traditionally organized lower level governments? d)How will permanent austerity shape these new national gover- nance strategies? Most European national governments will be dealing with large national debt obligations for at least the next decade. Facing substantial economic competition with Asian countries, these European governments will have option but to limit taxes and to reduce welfare spending, including for health care (Saltman, and de Roo, 2011). How will this permanent shrinkage of revenues affect the new strategies of national governments to increase their role in their health sec- tors? this ongoing revenue scarcity favour a differing mix of structural and non-structural initiatives than might otherwise be preferred? While these additional issues raise questions that the evidence pre- sented here does not allow for an answer, they are nonetheless very much a part of the current policy-making environment. Finding responses to them will necessarily be part of the process of deve- loping reforms if national governments are to achieve their central objectives. PART II COUNTRY GOVERNANCE PROFILES Governance model and recent changes Responsibilities for funding and managing health care services in have traditionally been divided between the national govern- ment, and the six states and two territories. Thus, the power of individual actors to plan and regulate is usually limited and the Australian (Commonwealth) Government and the States must agree on all major health reform steps. Recent reforms in 2004 and 2011 have reflected continuous attempts of the Commonwealth government to assume a higher level of control in some areas. This has usually worked through intergovernmental agreements and fun- ding mechanisms and more recently by creating national regula- tory, planning and oversight agencies. Policy priorities and tools Health professional regulation has traditionally been a responsibility of the 8 states and territories with separate health professional planning boards. In 2010, health professional regulation was centralized. Initially one national health professional board was to be established for all health professionals but some health pro- fessional groups opposed to the plans for joint regulation and planning so that eventually 10 national boards for each group of health professionals were established. A national oversight agency, the , was set up to ensure accountability of the national boards. Health Workforce is also a new agency created for providing national level advice, coordination and consultation on health professional re- cruitment and retention. The purpose is to tackle the progressive shortage of health professionals in and work towards a nationally coherent approach to health professional staffing in hos- pitals. Primary care has become subject to a nation-wide policy through Medicare Locals which are integrated local planning units funded by the Commonwealth. Currently about 30 Medicare Locals are set up each composed of about 100–300 health professionals of different disciplines. The intention is to further roll them out. Medicare locals are expected to encourage collaboration amongst GPs and other health professionals, the integration and continuity of care, and enhance continued training. There are financial incentives for GPs who are willing to sign up with Care locals but they will continue to operate as private practitioners. In addition to general practice, a small number of polyclinics will be established as community health centres that will work in an interdisciplinary approach to care provision. General practitioners who fear to lose patients to them have not supported the of these polyclinics, but the opposition is not been very fierce since overall the demand for health care succeeds the supply in and thus polyclinics are not likely to change the GPs position working in private practice. A national agency for disease prevention has been established in 2011, the , as a partner- ship of the Commonwealth government, State governments and the private sector. It will focus on strengthening the individual responsibility towards prevention and provide recommendations. Critics of the agency have argued that it will not have the leverage to influence the health environment towards a collective and commu- nity approach to disease prevention. The most recent reform as of 2011 also influences funding and governance arrangements for hospitals. Overall the Commonwealth government will assume a stronger role but super- vision and provision of hospital care remains in the hands of the States. Additional funding is provided nationally covering block grants for public hospitals and performance targets will be deve- loped nationally starting with waiting time targets on elective surgery and emergency care. In addition, there are plans to establish local hospital networks grouping up to 4 hospitals together. Pay- ments of these groups for the provision of services in the public scheme will follow a national pricing system. For each patient under the public scheme hospital services will be paid of the efficient price of the respective . The newly established Hospital Pricing Authority will determine hos- pital prices for the local hospital networks. The scheme is expected to improve efficiency and level out the substantial variation in hos- pital prices. Another area with increased funding and policy responsibility of the Commonwealth is for care for the elderly including long-term home and community care with the exception of and Western where they will continue as joint . The Commonwealth funds care for the elderly, in particular long-term care in residential homes, under the Aged Care Act 1997. Care for people in their own homes in the community, and also support for their carers, is provided under an intergovernmental agreement through the Home and Community Care (HACC) program. Three new national agencies will be established to increase leve- rage of the national government on hospital funding and perfor- mance management: Hospital Pricing Authority is planned in order to establish a national pricing scheme for hospi- tal services. A National Health Funding Pool will make payments to hospitals, and a National Health Performance Authority is estab- to monitor and publicly report on hospital performance. In addition, the Australian Commission on Safety and Quality in Health Care – an agency that sets out standards for safety and quality of care – has already become a statutory national entity. The health care system in is characterized by the division of governance responsibilities of the States and the Common- wealth Government. Major changes have to be negotiated through bodies jointly such as in . The trend has been a growing coordination of strategies and policies such as in funding and provision of care to ensure more equal access to care; level out differences in prices of health services; increase nation- wide performance on quality, transparency and public accountability of health care providers; and increase the continuity of care between the different health care sectors. The recent trend to coordinate policies at Commonwealth level has arguably diminished the auto- nomy of States and Territories. In addition, by incentivising health care providers to sign up to certain care groupings the attempt is made to create better conditions for aligning care providers to common strategies and policies. The scope of services provided however is not fundamentally revisited, and rationing takes place by waiting lists only. The progressive shortage of health pro- fessionals in will likely be one of the factors restraining fundamental changes. Governance model and recent changes