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International Health Care Management
Part 3b
Steffen FleßaInstitute of Health Care Management
University of Greifswald
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Supply of Health Services: Structure
1 International Public Health2 Demand for Health Services
3 Supply of Health Services3.1 Factors of Production
3.1.1 Buildings and Plants3.1.2 Staff3.1.3 Problems of Donations
3.2 Spatial Structure of Supply3.3 Levels of Care3.4 Provider Portfolio
4 Health Reforms
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3.2 Spatial Structure of Supply
Spatial Disparity: uneven distribution of resources in developing countries
Example: Kenya
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Health Expenditure per capita(1,000 p.a., at 2010 prices)
Source: Simon 2014
Health Expenditure per capita (1,000 p.a., at 2010 prices)
GDP per capita (1,000 p.a., at 2010 prices)
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Health Facilities (1959=308; 2002=2052)
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Development of Catchment Areas
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Formation of Hexagons
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Hierarchical Structures
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AccessibilityA: Distance 2003B: Distance 2008C: ImprovementD: Share of population > 5 km
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Why are they not coming from there?
Ziwa Nyassa
Itete
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Why are they not coming from there?
Ziwa Nyassa
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Ziwa Nyassa
Why are they not coming from there?
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Where should we start investing and where stop?
Lake
10 km
D12
D1
D13
D2
D3 D4
D5 D6
D7
D8
D10 D11
D15
D14
D9
D17
D18
D19 D16
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Example: Health Facilities in Three Kenyan Districts
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Quality in Structure
48
32
3
23
15
7
35
9
0
10
20
30
40
50
60
Nairobi Central Coast Eastern North Eastern
Nyanza Rift Valley Western
Prop
orti
on [
%]
% of Health Facilities Complying with National Minimum Standard (e.g. regular supply of water
and electricity)
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3.3 Levels of Care
Dorfgesundheitshelfer, Traditionelle Hebammen
Dispensarien
Gesundheitszentren
Distriktkrankenhäuser
Regionalkrankenhäuser
Tertiär-
Krankenhäuser
Health Pyramid
Village Health Workers, Traditional Midwives
Dispensaries
Health Care Centers
District Hospitals
Regional Hospitals
Tertiary Hospitals
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Quality in Structure and Level of CareKenya Service Provision Assessment Survey (2004)
0
5
10
15
20
25
30
35
40
Hopitals Health Centers Dispensaries
Prop
orti
on [%
]
% of Health Facilities Complying with National Minimum Standard
(e.g. regular supply of water and electricity)
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Quality in Structure (Cost per visit in the ambulance of a private hospital, Kenya 2005)
525 578
784 835 864982 1,016 1,024
1,170
1,376 1,384
1,6071,750
1,941
2,171 2,173
2,587 2,600
3,230
3,427
4,011
4,218
1,432
-
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
Hospital Code
Cost
per
Am
bula
nce
Vis
it [
Ksh
]
Hospital Code
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Quality in Structure (Cost per visit in the ambulance of a private hospital, Kenya 2005)
525 578
784 835 864982 1,016 1,024
1,170
1,376 1,384
1,6071,750
1,941
2,171 2,173
2,587 2,600
3,230
3,427
4,011
4,218
1,432
-
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
Hospital CodeHospital Code
There are private hospitals of low quality for the
poorer!
There are also private hospitals of high quality for
the rich!
Cost
per
Am
bula
nce
Vis
it [
Ksh
]
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Cost per Admission 2007(Kenya Costing Model)
Publ. Distr.Hospital
Publ. Prov.Hospital
NGO. Distr.Hospital
Priv. Distr.Hospital
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Competitive Situation in Relation to Traditional Medicine
Spiritual Background of Medicine – i.e. disabilities and taboos– Child mortality and fontanel– Evil eye, protecting small children– Cycle and reincarnation, „living dead“
Forms of Traditional Healers– Traditional midwives– Herbalists– Traditional surgeons– Spiritual healers
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3.4 Provider Portfolio
• Trustee:– Public
• federal• provincial• districts
– Nonprofit– Commercial
• Who should supply what on what level?• How should collaboration look like?
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Provider Portfolio
Organizations
For-Profit Org. Non-Profit Org.
Governmental NPOs
Economic NPO
Socio-cultural
NPO
Political NPO
Charitable NPO
Private Organizations
Church Social Work
………….
………….
CSO i.n.s.
Civil Society Organisations i.b.s.
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NPOs
• NPO: limitations to allocations of profits• CSO in a broader sense: collective term for
charitable, political as well as socio-cultural NPOs.
• CSO in a narrower sense: civil society’s participation in political decision making (Advocacy). Political NPO
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Collaboration of Providers
Serengeti
Haydom
Iambi
Singida
Dongobesh
Mbulu Lutheran Hospital
Government Hospital
Lutheran Dispensary
Government Dispensary
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Supervision?
Serengeti
Haydom
Iambi
Singida
Dongobesh
Mbulu Lutheran Hospital
Government Hospital
Lutheran Dispensary
Government Dispensary
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Public-Private Partnership (PPP)
• Assumption: there are public goods the state has to provide– Not pareto optimal– Insufficient provision of certain (poverty) groups
• But: This does not imply the state operating as financer
• The state can collaborate with the private economy regarding the provision of public goods
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PPP: Deviating Criteria• Exclusive partnership of state with commercial
businesses vs. additionally partnering with NPOs• Partnership via market regulation (through prices) vs.
partnerships based on long-term contracts and agreements
• Partnering with non-governmental organizations performing public tasks vs. participation of the private economy in public production (i.e. financing public hospitals via private leasing companies)
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PPP - Versions Government of Kenya
Other sectors Health sector
Private
Other sectors
4 3
1a
2
Health sector
NPO secto
r
FPO sector
1b
Gov
ernm
ent o
f G
erm
any
5
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4 Health Care Systems and Health Care Reforms
4.1 Costs4.2 Options of Funding4.3 Health Care Systems by International Comparison4.4 Health Care Reforms
4.4.1 Objectives4.4.2 Reform Alternatives
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4.1 Costs
• Cost-of-Illness– Content: all economically feasible negative results of
disease and death– Concept: Rice (1966); today standard– Examples: Cost-of-Illness studies
• Xie (1996): Alcohol and drugs in Ontario• Henke (1997): Disease in Germany• Welte, König, Leidl (2000): Consumption of cigarettes in Germany
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Cost-of-Illness
Intangible Costs Tangible Costs
Health Services Costs Household Costs
Non-Core Costs Core Costs
Prevention
Curative Care
Administration
Training
Research
Direct HH Costs Indirect HH Costs
Loss of harvest
Loss of labour
Transport for patient and relatives
Accomodation for relatives
Buildings, i.e. for disabled
Diet, i.e. special food
User Fees, drug bills etc.
Loss of salary
Loss of education
District Production Function: Y=Y(K,L)
Direct Costs
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Cost-of-Illness
Intangible Costs Tangible Costs
Health Services Costs Household Costs
Non-Core Costs Core Costs
Prevention
Curative Care
Administration
Training
Research
Direct HH Costs Indirect HH Costs
Loss of harvest
Loss of labour
Transport for patient and relatives
Accomodation for relatives
Buildings, i.e. for disabled
Diet, i.e. special food
User Fees, drug bills etc.
Loss of salary
Loss of education
District Production Function: Y=Y(K,L)
Direct Costs
Cost-of-Illness
Intangible Costs Tangible Costs
Personal suffering. i.e. caused by grief,
pain, longing, …Measurable only
indirectly in assessing quality
of life
Directly or indirectly
resulting in consumption of
resourcesUsually
quantitatively measurable
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Cost-of-Illness
Intangible Costs Tangible Costs
Health Services Costs Household Costs
Non-Core Costs Core Costs
Prevention
Curative Care
Administration
Training
Research
Direct HH Costs Indirect HH Costs
Loss of harvest
Loss of labour
Transport for patient and relatives
Accomodation for relatives
Buildings, i.e. for disabled
Diet, i.e. special food
User Fees, drug bills etc.
Loss of salary
Loss of education
District Production Function: Y=Y(K,L)
Direct Costs
Tangible Costs
Household Costs Health Services Costs
Costs of performing institutions, usually well documented
Costs of household consuming
health services,
usually bad documentatio
n
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Cost-of-Illness
Intangible Costs Tangible Costs
Health Services Costs Household Costs
Non-Core Costs Core Costs
Prevention
Curative Care
Administration
Training
Research
Direct HH Costs Indirect HH Costs
Loss of harvest
Loss of labour
Transport for patient and relatives
Accomodation for relatives
Buildings, i.e. for disabled
Diet, i.e. special food
User Fees, drug bills etc.
Loss of salary
Loss of education
District Production Function: Y=Y(K,L)
Direct Costs
Non-Core Costs Core Costs
Health Services Costs
Administration, Teaching,
Research
All Costs of Prevention and
Treatment (programs,
dispensaries, hospitals etc.)
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Cost-of-Illness
Intangible Costs Tangible Costs
Health Services Costs Household Costs
Non-Core Costs Core Costs
Prevention
Curative Care
Administration
Training
Research
Direct HH Costs Indirect HH Costs
Loss of harvest
Loss of labour
Transport for patient and relatives
Accomodation for relatives
Buildings, i.e. for disabled
Diet, i.e. special food
User Fees, drug bills etc.
Loss of salary
Loss of education
District Production Function: Y=Y(K,L)
Direct Costs
Household Costs
Direct HH Costs Indirect HH Costs
Transport, Fees, Diet,
Construction
Loss in Labor, Crops, Income,
Education, Domestic Product
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Determining Household Costs
Direct Costs
Indirect Costs- Human Capital Approach
- Friction Costs Method
- Willingness-to-pay ≠ ability to pay
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Cost-of-Illness
Intangible Costs Tangible Costs
Health Services Costs Household Costs
Non-Core Costs Core Costs
Prevention
Curative Care
Administration
Training
Research
Direct HH Costs Indirect HH Costs
Loss of harvest
Loss of labour
Transport for patient and relatives
Accomodation for relatives
Buildings, i.e. for disabled
Diet, i.e. special food
User Fees, drug bills etc.
Loss of salary
Loss of education
District Production Function: Y=Y(K,L)
Direct Costs
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4.2 Options of Funding
SOCIAL HEALTH
INSURANCE
PRIVATE HEALTH
INSURANCE
GOVERNMENT
Dir
ect I
nput
HEALTH CARE FACILITIES
HE
AL
TH
SE
RV
ICE
S
POPULATION DONORS
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Concepts of Remuneration
• Input-basierte Finanzierung
• Output-basierte Finanzierung
• Output-based Aid
HEALTH FUNDING
Input-based funding
Output-based funding
Combined funding
Needs
Population
Beds
Admissions
Patient Days
Lump Sums
Buildings
Plants
Materials
Staff
Other
Lump Sum Funding
Nursing Rates / DRGs
Services
based on based on
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Input-Based Funding
Client
Funding Entity (Health Insurer, Government)
Provider Service
Fixed Budget
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Input-Based Funding: Ways
MINISTRY of HEALTH (MoH)
SERVICE PROVIDER
FINANCIAL SERVICE PROVIDER
ASSOCIATIONS
REGION
DISTRICT
HEALTH INSURANCE
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Output-Based Funding
Client
Funding Entity (Health Insurance, Government)
Provider Service
Proof of Authorization
Proof of Authorization
Bill Reimbursement
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57Source: Obermann 2014
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Output-Based Aid
Client
Distributor
Voucher Management Agency
Voucher Service Provider
Voucher
pays Voucher
service
Voucher
Claim Reimburse-ment
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Example: Kenya
• As of June 2006 for– Family planning– Delivery– Gender Violence Recovery (GVR)
• Cost (here: delivery)– Voucher: 200 Ksh– Reimbursement
• Normal delivery: (incl. 4 ante-natal): 5000 Ksh• C-Section: 20.000 Ksh
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0
5.000.000
10.000.000
15.000.000
20.000.000
25.000.000
30.000.000
35.000.000
40.000.000
0
100.000
200.000
300.000
400.000
500.000
600.000
0 10 20 30 40
Su
bsi
dy
p.a
. [U
S$]
Am
ou
nt o
f V
ou
cher
s p
.a.
Poverty [% of population]
Amount of Vouchers p.a. Subsidy p.a. [US$]
Subsidies
(Births)
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4.3 Health Care Systems by International Comparison
• Overview – Criteria for Classification
• Organization of funding (predominantly)– Social insurance– Private insurance – Insurance-free health care system (developing countries)
• Organization of service providing – Private service providers– Public organizations provide services– Non-governmental, non-profit organizations provide services
• Market Interventions– Free negotiations on prices– Market interventions of the state
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Outpatient: privateInpatient: predominantly public
Social InsuranceAustria
Predominantly privateSocial Insurance with Basic Insurance
Netherlands
Outpatient: privateInpatient: partly public
Social InsuranceGermany
Outpatient: privateInpatient: partly publicManaged Care Organizations
Private Insurance Accompanied by Subsidies
Switzerland
Private Service Providers,Managed Care Organizations
Private InsuranceUSA
Predominating Provision of Services
Predominating Organization of
Funding
Country
Examples
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Predominantly publicNational Health Service
Sweden
Predominantly publicNational Health Service
United Kingdom
Predominantly publicNational Health Service with Funding via Premiums
Italy
Outpatient: privateInpatient: public
National Health Service
Canada
Predominantly publicNational Health Service with Funding via Premiums
Greece
Outpatient: privateInpatient: predominantly public
Social InsuranceFrance
Predominating Provision of Services
Predominating Organization of
Funding
Country
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National Health Service in the United Kingdom
• Overview – Founded: 1948 – Dimension: almost 1.000.000 employees– Funding: predominantly tax funded
• History (until the end of WW II)– Social insurance for workers– Registered general practitioners – Capitation fee for general practitioners– Hospitals: not covered – Beveridge-Report (1944): public health care planning,
health is considered a basic right
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National Health Service (cont.)
• Organization – National Health Services Executive (top management
directly supervised by ministry of health)– Health Authorities responsible for 500.000 inhabitants
each– Primary Physician System: general practitioner acts as
gatekeeper (local level)• Remuneration
– Lump Sum per capita, part of remuneration is performance-related, resident registers with one physician
– Target payments, special payment for successes, i.e. vaccination quota or participation in trainings
– Few fee-for-service remunerations especially for patients with chronic diseases
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• Funding – Basics: 90 % via tax return, low co-payment
(i.e. drugs) – Allocation of budget to Health Authorities via a
specific complex system based on demographic and epidemiologic data
– Allocation leads to down scaling, investment backlog, low income for physicians
– Internal Markets: Local Health Authorities can sign contracts with service providers (i.e. hospitals) that are not part of NHS. This leads to some extend of competition.
National Health Service (cont.)
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The US Health Care System
• Funding – Predominantly private health insurance premiums – Predominantly employment based
• Public Sector – Medicare, tax funded, > 65 years of age – Medicaid, support for the (very) poor– Veterans Health Administration (primarily veterans
suffering from long-term effects)• Underlying Issue: up to 50 million without
(sufficient) health coverage
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Number of US-Americans Covered Under Various Forms of Health Insurance [absolute]
http://de.wikipedia.org/wiki/Gesundheitssystem_der_Vereinigten_Staaten#Gesundheitsreform_2010
Maxi-mumPre-
miums!
Employment Based Insurance
Private Insurance
No Insurance
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Proportion of Population that does not have Health Insurance nor is entitled to Public Health Coverage [%]
http://de.wikipedia.org/wiki/Gesundheitssystem_der_Vereinigten_Staaten#Gesundheitsreform_2010
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Medicare
• Health Insurance for older people that are not covered otherwise (problem: since insurance is predominantly employment based they stop at pension age)
• Funding: via taxes• Dimension: 39 million Americans (largest program in
the US!) • Insurance for Americans > 65 years, disabled people
and patients suffering from renal failure
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Medicare
• Part A: compulsory, hospitals services and outpatient care
• Part B: optional additional coverage, part of outpatient physician and hospital services, expenses for additional hospital care (Medigap) as well as medical remedies and
• Co-payment• Limitations to services • Remuneration of service providers
– Strict budgeting – DRG-System
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Medicaid
• Goal: Health Coverage for People with Low Income
• Funding: via taxes • Assessment Ceiling: variations within the
states • „Basic Package“
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Private Insurance
• Normally Employment Based • Employer bears (part of) premium payment which is
tax deductible as non-wage labor costs• Problems:
– Employee looses coverage in unemployment – Employee looses coverage when entering retirement– Employee is tied to the insurance the employer has a
contract with
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Critical View on the System
• United States National Health Care Act (US Congressional Bill, House of Representatives: HR 676)
• Content: Expanded and Improved Medicare “for Everybody”
• Consignor: John Conyers – 24.1.2007– 26.1.2009
• Goal: "To provide for comprehensive health insurance coverage for all United States residents, and for other purposes… "to ensure that every American, regardless of income, employment status, or race, has access to quality, affordable health care services."
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Health Care Reform 2010 (Obamacare)
• Patient Protection and Affordable Care Act (PPACA)– 23.3.2010
• Content – Obligatory health insurance (partly subsidies/vouchers))– Health Insurance companies have to accept people despite their
medical background– Special conditions for children (i.e. co-insurance for family members
up to age 26)– Tax reliefs for businesses that insure their employees– Limitation of premiums (i.e. older people)– Broader access to Medicare (133% of poverty line, i.e. 14.856 US$ for
a single living person in 2012)– Subsidies for poorer people– Tax deductibility for premiums
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Criticism
• Criticism– State intervention in functioning system of market
economy– Accusation of socialism (“state takes over the
health care industry“)– Cost increase– Public indebtedness– Increasing unemployment– Intervention in federal system
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Evaluation
• No change in system• Financial contribution to poorer people so
they can afford private health insurance• Expenses: 1 Trillion US$ over 10 years• Success: has to be devalued
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4.4 Health Care Reforms 4.4.1 Objectives
System of Values and Objectives in Health Care
Values Objectives
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Examples for Values
• Freedom • Equality• Justice• Fraternity• Unity• Charity• …
A question of the view on
human beings
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Examples for Objectives
• Minimizing Mortality • Minimizing Prevalence• Maximizing Quality of Life• Sustainability• Affordability• Efficiency• Participation
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Objectives and Side Conditions
Objectives- Optimization (Max. / Min.)- possibly not positive (i.e. Maximizing Profits Minimizing Losses)
Side Conditions- Satisfaction- Strict Compliance
Ethical Demands- Humanity as goal- Justice as side condition
Target Groups
- Population groups that are effected by the objectives
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Task
Develop a system of values and objectives for a health district in a country of your choice.
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LEVEL of VALUES Values Target Groups
LEVEL of OBJECTIVESObjectives Side Conditions
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4.4.2 Reform Alternatives
• Making use of existing potential for improvement • Funding Reforms
– Public Health Care Budgets– Foreign Funding– Patient Fees– Health Insurances
• Reforms in Health Care Structure– Secondary and Tertiary Hospitals– District Hospitals– Dispensaries/Health Care Centers– Programs for Prevention
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Task
• Brain Storming: Develop a list of measures for health care reform in the country of your choice.
• Evaluate various measures according to your system of objectives.
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Measure Objective Implementation
Cost Willigness
++
positive effect
+ indirect positive effect
o no effect
- indirect negative effect
-- negative effect
? no prediction possible