Health Care Systems’

Working Conference Health Services Research in Europe, 8 & 9 April 2010. Keynote presentation by Reinhard Busse, TU Berlin. Parallel session 8 April ‘Health care systems’.

Health Services Research in Europe: Health care systems

Reinhard Busse and Marcial Velasco Garrido TU Berlin

Definition of “Health systems“ (I) people, institutions and resources, arranged together in accordance with established policies, to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health.

European Observatory for Health Systems and Policies (2007). Glossary. http://www.euro.who.int/observatory/Glossary/Toppage.

www.healthservicesresearch.eu Working Conference Health Services Research in Europe, 8 & 9 April 2010. Keynote presentation by Reinhard Busse, TU Berlin. Parallel session 8 April ‘Health care systems’.

FUNCTIONS GOALS / OUTCOMES THE SYSTEM PERFORM S OF THE SYSTEM

Stewardship

I Health Creating resources (level and equity) N (investment and training)

Responsiveness P Service delivery (to people’s non-medical (personal and population- expectations) U based) Financial protection Financing (and fair distribution of burden of T (collecting, pooling and }{funding) purchasing)

Definition of “Health systems“ (II) … ensemble of all public and private organizations, institutions and resources mandated to improve, maintain or restore health. … encompass both personal and population services, as well as activities to influence the policies and actions of other sectors to address the social, environmental and economic determinants of health.

WHO European Ministerial Conference on Health Systems (2008). Tallinn Charter: Health Systems for Health and Wealth. Resolution EUR/RC58/R4.

Health Production Model for Health Systems Research

“actions of other sectors to address the determinants of health” Environment Intermediate Nutrition/ agriculture dependent Final Other sectors variables dependent Population variables health “public and private organizations, institutions and status (need) Patients Health care outcome: Health Human Process satisfaction, gain/ complica- resources Structures tions etc. and Outcome organisation Techno- logies resources to improve, maintain or restore health” Independent Financial variable of resources Stewardship/ regulation/ incentives health systems “activities to influence the policies“ research! (?)

Personnel sufficient Needs-based, and well qualified? Patients satisfied, equitable Institutions of high standards? services safe and access? Technologies effective? of high quality?

Environment Nutrition/ agriculture Other sectors Population health status (need) Patients Health care outcome: Health Human Process satisfaction, gain/ complica- resources Structures tions etc. and Outcome organisation Techno- adequate? logies Health care system Resource creation

Financial Utilization responsive, How much? resources appropriate, coordinated …? Is it worth it Fair and sustainable funding? (cost-effective)?

Triangular Model for Health Systems Research (focussing on the “independent” variables)

Pooling

Purchasing Collecting

Contracting/ Raising financial reimbursing resources Regulation

Resource creation Service provision

Health Systems in Transition: Template for analysis. European Observatory on Health Systems and Policies.

Topics for Health Systems Research (I)

Area Topics

Service delivery/ Availability, supply provision Accessibility access Acceptability Coverage, benefit basket/ package, entitlements Waiting time, waiting lists Utilization Responsiveness, Satisfaction Financing/ Financing expenditure Funding Payment of providers Reimbursement Purchasing Allocation Equity/Fairness

Topics for Health Systems Research (II)

Resource Professional education creation Research and Development Innovation management Knowledge generation and management Public health intelligence

Stewardship Planning, Health Plans Health Policy, Policy Making, Health Care Reform Centralization/Decentralization/Devolution Privatisation/Recommunalisation Commissioning Licensing Accreditation Contracting

Search Strategy • Databases PubMed, EMBASE • 2004-2010 • Items with Abstract, Humans

• MeSH Terms MeSH Module Country Module Restriction Module ... Healthcare system ... OR OR OR Cyprus Health planning AND AND Health care system OR OR

Health policy France OR Health system OR OR

......

Bibliometric Analysis

• Reference Manager®, Excel® • Year • Country • Language •Keyword

Cumulative number of publications

30000

25000 26848

22679 20000

17563 15000

10000 12569

7939 5000 3922 0 2004 2005 2006 2007 2008 2009

Publications per year; change (2004-2009)

Year No. of % of Database Absolute % difference Publications difference to to previous previous year year 2004 3922 14.6% - - 2005 4017 14.9% 95 2.4% 2006 4630 17.2% 613 15.3% 2007 4994 18.5% 364 7.9% 2008 5116 19.0% 122 2.4% 2009 4169 15.5% -947 -18.5%

Ranks (top-10)

Number fro m (co untry in address field) Number o n (co untry in title, abstract o r keywo rd field)

Crude per 10,000 pop per billion USD GDP Crude per 10,000 pop per billion USD GDP 0

1 ISR

2 NL

3 D S 4 N GEO 5 F Rank 6 ICE IRL

8 CH

10 FIN United Kingdom* Netherlands* Germany* Sweden* France* Italy* Spain* Switzerland# Israel Turkey Iceland# Norway# Ireland* Denmark* Finland* Malta* M ontenegro Georgia Tajikistan Estonia*

% publications from country on that country 0 102030405060708090100 Albania Armenia Austria* Azerbaijan Bulgaria* Croatia Denmark* Estonia* Georgia Germany* Researchers from these countries Hungary* Iceland# Kazakhstan Latvia* publish only on their own country Lithuania* Luxembourg* M ontenegro (often only few publications) Æ no capacity Portugal* Republic of M oldova Romania* or interest to study other countries Serbia Slovenia* Sweden* The Former Turkey Ukraine Uzbekistan Netherlands* Norway# Ireland* Belgium* Switzerland# Italy* Spain* Finland* Researchers from these countries Israel Greece* Poland* publish mainly on their own country France* Czech Republic* Russian Federation Bosnia and Cyprus* Slovakia* Malta* United Kingdom* Researchers from UK: the only ones with many publications on other countries

% publications on a country from that country

0 102030405060708090100

Sweden* Israel Turkey Finland* Netherlands* Publications on these countries Belgium* Switzerland# Greece* are mainly from local researchers Italy* United Kingdom* Norway# Denmark* France* Croatia Bosnia and Herzegovina Malta* Spain* Lithuania* Austria* Slovenia* Luxembourg* Serbia Ireland* Czech Republic* Publications on M ontenegro Portugal* Estonia* these countries are Iceland# Germany* both from local and Cyprus* Romania* Hungary* other researchers Uzbekistan Bulgaria* Poland* Slovakia* Georgia Azerbaijan Ukraine Armenia FRY M acedonia Kazakhstan Republic of M oldova Latvia* Publications on these countries are Albania Russian Federation Belarus rarely or never from local Kyrgyzstan Tajikistan Turkmenistan researchers

Language distribution non-English publications (n=3341 or 13%) Hungarian 1% Hebrew Turkish 1% 1% Other 4% Norw egian Danish 3% 2%

Dutch 4% Italian German 5% 40% Polish 6%

Russian 6%

Spanish 9% French 18%

References by country (Address Field) 2004-2009 (top-10)

350

300

250

200

150

100

50 2004 2005 2006 2007 2008 2009

UK/10 Netherlands* Germany* Sweden* France* Italy* Spain* Switzerland# Israel Turkey

References by country (Address Field) 2004-2009 (11th -20th)

160

140

120

100

0 2004 2005 2006 2007 2008 2009

Norway# Ireland* Denmark* Belgium* Finland* Greece* Austria* Poland* Croatia Portugal*

References on a country (TiAbKw) 2004-2009 (top-10)

800

700

600

500

400

300

200

100

0 2004 2005 2006 2007 2008 2009

UK/2* Germany* Net herlands* Sweden* France* Italy* Spain* Swit zerland# Ireland* Norway#

References on a country (TiAbKw) 2004-2009 (11th -20th)

180

160

140

120

100

0 2004 2005 2006 2007 2008 2009

Israel Turkey Denmark* Belgium* Finland* Poland* Austria* Greece* Russian Federation Hungary*

Thematic Clusters

Satisfaction

0 5 10 15 20 25 30 35 40 45 50 55

Austria* Turkey Italy* Germany* Greece* Lithuania* France* Netherlands* Denmark* ! Czech n Spain* io Sweden* t Norway# au Slovakia* c Belgium* Israel th Finland* i Slovenia* w OVERALL d Switzerland te Luxembourg* re Poland* p Bulgaria* r UK* te Iceland n Ireland* i Portugal* e Estonia* b Hungary* o Romania* T Malta* Cyprus* Latvia*

% publications from country (Address field) % on (Abstract, titles, keyw ords field)

3.5% random sample of abstracts (n = 1000) for in-depth-analysis

80% really HSR, but less than 25% on health systems (macro level): n=232

Thematic clusters in sample

Conclusions

• Literature search -> sizeable amount of work but low specificity to identify “health systems research” (rather than HSR in general) and probably low sensitivity (books, grey literature) • Common understanding of definitions, scope and necessary/ “best” methods? Further work ... • However, certain areas – especially regarding impact of regulation (e.g. privatization, accreditation/ licensing) – seem under-researched Æ identification of 3 topics to take discussion forward ...

Topics for “carousel” discussions (1) and selected corresponding contributions • Methods to evaluate health care reforms – Methodol. approach for measuring health system ... (16) – Factorial validation of a balanced-scorecard ... (17) – Development and application of an instrument ... (19) – Overcoming the challenge of policy evaluation ... (20) – Evaluating impact of the 2007 structural reform ... (22) – Systematic reviews in all areas of health services ... (29) – Health care reform – a well considered and ... (31) – Public health services – evaluation ... in Bulgaria (33) – The impact of healthcare reforms ... in Ireland (35) • Markets and competition/ Role of private sector • Workforce planning and professional mobility

Topics for “carousel” discussions (2) and selected corresponding contributions • Methods to evaluate health care reforms • Markets and competition/ Role of private sector – Markets, medicine, management: Hospital ... (13) – Competitive behaviour in health care and provider ... (14) – Is competition and integration incompatible ... (27) – For-profit hospitals, a comparative and longitudinal ... (30) – Privatization of health care in Poland – aims, ... (32) – Public-private partnerships in the Portuguese ... (36) • Workforce planning and professional mobility

Topics for “carousel” discussions (3) and selected corresponding contributions • Methods to evaluate health care reforms • Markets and competition/ Role of private sector • Workforce planning and professional mobility – Challenges of securing GP workforce in ... Finland (12) – From staff-mix to skill-mix and beyond: a ... (15) – Migration of health care personnel: Poland (18) – Health workforce in Europe – managing mobility ... (21) – Health manpower planning in EU countries ... (165)