On the structure and organisation of NORDIC HEALTH CARE SYSTEMS

1. On the structure and organisation ofNORDIC HEALTH CARE SYSTEMS Pia Maria Jonsson, MD PhD Senior Researcher Medical Management Centrum, MMC Karolinska Institutet pia.maria.jonsson@ki.se +46-70-990 1427, +358-40-527 1640

2. H E A L T H E Q U I T Y E Q U A L I T Y Q U A L I T YC O S T-E F F E C T I V E N E S S F I N A N C I N G O R G A N I S A T I O N R E G U L A T I O N M O N I T O R I N G

3. ”THE NORDIC MODEL” • Public systems, either through ownership or requiring private actors to contract with public bodies • Predominantly tax-based financing • Decentralized responsibility for the provision of services • Equity of access high up on political agenda

4. STRENGTHS OF THE NORDIC SYSTEMS • Good population health • Access to care on relatively equal terms (most inhabitants included in the systems) • Democratic rules

5. PROBLEMS • Demographics – economy – technology – consumer expectations • Regional variations in resources, production volumes, quality, and accessibility • Lack of responsiveness - consumer dissatisfaction – political problems • On the other hand: Local /regional autonomy and decision-making close to citizens highly appreciated!

6. ECONOMIC DEVELOPMENTOECDHealthData2007

7. Health expenditure per capita, public and private, 2005

8. Total health expenditure as a share of GDP, 2005

9. Health expenditure per capita and GDP per capita, 2005

10. Annual average growth rate in real health expenditure per capita, 1995-2005

11. HEALTH CARE RESOURCES 2005 Source: OECD Health Data 2007

12. Acute care hospital beds per 1 000 population,1990 and 2005 • 2004.

13. HEALTH CARE REFORM Frameworks and models • Responsibility: Political - Economic - Administrative /operative • The ”iron triangle”: Patients - Producers - ”Third party” payers • Classification of reform strategies (Saltman et al.): Demand side - e.g. freedom of choice, maximum waiting-time guarantees Supply side – purchaser-provider split, activity based funding (DRGs) etc.

14. HEALTH CARE REFORM in the Nordic countries • 1990´s ”first wave” Looking for increased productivity and efficiency - decentralisation - New Public Management – improved patient rights • 2000´s Looking for high and even quality and accessibility – centralisation – increased national steering and regulation?

15. NORWAY: Hospital Reform 2002 • Objectives: Enhancing state government steering, equitable service provision, high quality, responsiveness to consumer demand, efficient use of resources, respecting patient integrity. • The state took over the responsibility for both financing and organising the services • 5(4) Regional Health Authorities (RHA), 33 Local Health Enterprise (LHA, public hospitals including pharmacies) • RHA: 1) Owner (state) representative 2) Responsible for organising specialist care according to population needs and in concordance with legislation (can also purchase services) Also research, teaching, patient information etc.

16. Evaluation of the Impact of Hospital Reform, NRC 2007 • Quicker increase in production -> access improved, somewhat shorter waiting lists • Hospital productivity increased somewhat • Regional variations decreased inside RHAs, but not between them • Some centralisation of advanced care, but less advanced care not decentralised as expected – private sector • Priority setting did not improve – waiting times shortened especially in low-priority patient groups

17. DENMARK: Structure reform 2005-2007 • Objectives: Higher quality without increased taxation, shorter waiting-times in specialist care, international top know how. Strengthening local democracy through stronger municipalities. Clearer responsibilities. Better co-ordinated services to weak population groups. • 14 counties -> 5 regions, locally elected political leadership, no taxation right. Funding from the state (80%), municipalities (20%) • 275 -> 100 municipalities, at least 30.000 pop. (or collaboration with neighbours).Prevention, health promotion, rehabilitation.

18. Issues • The financing model – lack of congruence • State governance – centralisation and decentralisation • Primary health care /public health interventions, primary care physicians private practitioners

19. SWEDEN: Committee on Public Responsibility 2003-2007 • Better national (state) coordination – dividedintosix to ninecounties /regions in all national functions, improvedsteering, coordinated supervision • Six to nine regions (regionkommuner) instead of counties – the same division as for national administration, new responsibilites in regional planning • Regional responsibility for health services, uniform stategovernance and stewardship, legislation on patient rights • Responsibilities of the municipalitiesclarified, no structuralchanges

20. SWEDEN: Committee on Public Responsibility 2003-2007 • No changes in the distribution of responsibilities for financing and organisation of services • ”Self-organisation” starting 2007 in dialogue with the national government, to be finished by the elections 2010 • Accomplished by 2014 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - • Political consensus in the Committee, but not in the parties • Local and regional representatives mainlysupportive • Report from discussions with local and regional representatives, May 2008: • Seven regions, political support in six of them, but not in Stockholm

21. FINLAND • Structural reform PARAS: Legislative basis for ”spontaneous” merging of municipalities • New Health Care Act

22. Maximum waiting-time guaranteeSweden Finland • November 1, 2005 • Agreement bw. National government and SALAR • PHC, hospital care incl. mental health services • Extra funds annually according to county /region population base • No economic incentives built in the guarantee • March 1, 2005 • Legislation • PHC, hospital care, mental health, dentistry • 50M EUR to reduce accumulated waiting lists 2003-04, additional 380M EUR allocated by the municipalities 2002-07 • Supervision by TEO: fines?

23. Maximum waiting-time guaranteeSweden Finland • 0 – 7 – 90 – 90 rule • Specialist treatment at hospital in 3 months from verified need of care • Monitored by NBHW, SALAR • Assessment in PHC in 3 days, by hospital specialist in 3 weeks • Specialist treatment at hospital in 6 months from verified need of care • Monitored by Stakes, MoH, Local Authorities

24. Maximum waiting-time guaranteeSweden Finland • National medical indications for planned care supported by SALAR and the NBHW • WG:s in 15 clinical areas drafting documents • First qualitative study of attitudes and experiences in fall 2007 • National criteria for non-emergency care published and distributed by the MoH in 2005 • Implementation at healthcare units and compliance to guidelines studied in sample surveys

25. Finland EFFECTS • Shorter waiting lists, fewer waited longer than 6 mo. 2006, effect flattening 2007 • Regional variations somewhat decreasing • Redistribution effects between specialties, orthopaedics expanded, gynaecology and psychiatry down - reflected in physician staffing. • No verified changes in the distribution between specialist care /primary care - 60/40 • No initial trend changes in the frequency or costs of sick leaves in selected diagnoses

26. Finland REPORTED CHANGES IN LOCAL ORGANISATION AND WORKING PROCESSES • Better process descriptions /models • Queue administration • Private producers • Day surgery • More effective use of operation theaters • Leadership • Flexible working hours • Economic incentives • Shared responsibility with other personnel categories

27. Issues • Better, register-based monitoring of waiting times and the medical quality of care • Quick and smooth updating of national medical indications /criteria • Supervision, sanctions, fines?

28. COMMON TRENDS • Centralization, monitoring, regulation, legislation • State ownership (NO) • State (part)funding (DK, FIN) • Legislation (waiting list guarantee FIN) • Stronger national monitoring, regulation, supervision (DK, NO) • NPM still going strong - DRG - activity based funding - purchaser-provider split - increased diversity of provision - political and EU pressures

29. COMMON TRENDS • Patient /consumer empowerment - freedom of choice - ”patient-centered” care - transparent comparisons - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - • How to guarantee patient safety? • Staffing?

30. Kiitos – Tack för Eruppmärksamhet!