Funding, Provision, Regulation, Access Issues

Question 1

Learning Objective

Answer 1

• Public policy analysis
• The policy making process
• Economic thinking: Keynesianism and Neoliberalism
• Issues with healthcare provision
• Mechanisms for the public funding of care
• Governance for health
• The concept of complexity

Question 2

What is the public policy analysis?

Answer 2

• A public policy (for example, as relating to health, education, or defence) is a decided course of action, including preserving the status quo
• Policies are however dynamic and subject to change in the light of circumstances
• Health policy analysis has traditionally focused upon institutions to promote health and treat and care for the sick.

Question 3

What is the public policy analysis? (PART 2)

Answer 3

• Primary concerns are the organisation and structure of the health care system, including funding, and the allocation and prioritisation of health care resources.
• Increasingly, as knowledge of the multiple determinants of health has increased, health policy is seen as extending beyond the health system per se, towards multisectoral, whole of government, whole of society and health in all policies approaches

Question 4

Describe the policy making process

Answer 4

• The formal democratic model of government presents policy-making as a transparent process, with “policy actors” having accountable roles in the process
• The key policy actor’s are political parties, politicians, civil servants, as well as the voting public.
• However the political and economic interests of powerful elite groups can bypass this process
• For example powerful corporate interests (e.g. “Big Tobacco” or “Big Alcohol” may be able to negotiate directly with politicians and state officials outside formal policy making and consultative channels

Question 5

How is the implementation of policies carried out? (PART 1)

Answer 5

• In practice, the implementation of policy is a highly complex phenomena, and proceeds as a series of negotiations and compromises with conflicting sets of interests
• There is often a lack of correspondence between policy objectives and policy outcomes- termed an ‘implementation deficit’.
• This understanding led to the development of a variety of ‘ideal-type’ models.
• Top-down models generally recommend greater control, planning and hierarchy, identify the lies of authority and limits to control inherent in complex public administrative systems

Question 6

How is the implementation of policies carried out? (PART 2)

Answer 6

• Bottom-up models focus on the ‘concrete behaviours’ of those lower down the hierarchy charged with actually carrying out policy.
• Bottom-up model commend spontaneity, learning and adaptation as problem-solving techniques for effective policy implementation,
• Often ‘street level’, actors charged with the implementation of a policy must make choices between programmes that may conflict or interact with one another.

Question 7

What was Keynesian’s economical thinking about?

Answer 7

• Gave his name to the predominant economic thinking post WW2
• Government acts as provider of demand of last resort
• Provides for public goods where the market cannot value properly e.g. education, health, infrastructure, clean air and water, R and D
• Consistent with the human right to health and equalization of access to care
• Provides for Universal Health Coverage (UHC)
• Attempt to equalize outcomes of care
• Rationing of scarce resources based on medical need

Question 8

What was the second coming of Laissez faire and neoliberalism post 1970?

Answer 8

• Decline in 1970’s of political forces that support mixed economy
• Public Choice Theory-citizens drowned out by interest groups-entrust as little to the public realm as possible
• Rules and undermine the efficiency of markets
• The law should serve economic efficiency rRegulation is a deadweight.
• “Government is not the solution to our problem; government is the problem”- Ronald Reagan.

Question 9

What is meant by the health care provision? (PART 1)

Answer 9

• The ‘mix’ of health care provision refers to the combination of health care providers in a system: i.e. state-run or public; private or for-profit; voluntary; and informal
• Also important is the share of resources that are allocated to preventative, primary care, secondary care, rehabilitation, palliation, and long term care
• Notable preventive services in nearly all HIC’s represent a small fraction of total health expenditure (THE)-(approximately 3% in OECD countries.

Question 10

What is meant by the health care provision? (PART 2)

Answer 10

• These system characteristics are shaped by political, historical, cultural, and professional factors
• Also important commitment is commitment to equity, social solidarity, or conversely individual responsibility.
• Recently there has been a convergence between social insurance and national health systems models, because of the increasing use of the ‘public contracting model’ that seeks to separate providers from purchasers of health care.

Question 11

Public funding of care

Question 12

What are the mechanisms for the public funding of care? (Part 1)

Answer 12

• “Single payer” tax-based general revenues-provide care directly through state-owned and run facilities e.g. the UK, Canada
• Possibility of earmarked (hypothecated) health tax
• Social insurance financing e.g. Germany, France

Question 13

What are the mechanisms for the public funding of care? (Part 2)

Answer 13

• Individually based insurance e.g. United States-modified by the Affordable Care Act
• Support health care consumers directly through “vouchers”
• Health savings accounts plus catastrophic insurance

Question 14

How is HCS funded through direct taxation?

Answer 14

• The NHS in the UK is an example of a directly publicly funded “single payer” health system
• The model is also found in Nordic Countries, as well Canada, Australia and New Zealand, although organization and mechanisms differ
• Tax-funded models typically seek to pool risk across large populations
• Aim is to make health services available on a universal basis and achieve Universal Health Coverage

Question 15

Describe how insurance based systems work

Answer 15

• Policy-holders contribute on a regular. Employers often make a similar contribution
• The level of contribution can be assessed according to the health of individual (individual risk-based) or according to an ‘at-risk’ social group (social or community risk rating).
• Insurance based systems frequently include some public funding of services for social groups unable to afford health insurance or seen as poor insurance risks e.g. the unemployed, old age pensioners etc.
• Insurance bases systems are organizationally complex with less central government control
• Plural service provision and multiple insurance providers e.g. the United States, make cost control very difficult

Question 16

How does funding HCS through social insurance work?

Answer 16

• Examples are found in many European health care systems
• Social insurance is what is known as a ‘hypothecated tax’, a tax that is assigned to a specific purpose (i.e. TV licence fee)
• Social insurance embodies the principle of social solidarity, with contributions paid as a percentage of salary rather than individual health risk as in private insurance-based systems.
• Compared to NHS systems, social insurance funded systems usually have plural systems of service provision and often a closer interface between the public and private sectors

Question 17

Governance for health

Question 18

Define Governance

Answer 18

A specific framework of arrangements through which ‘rights and obligations are established and regulated, and through which policies and practices are effected

Question 19

Define Global health governance

Answer 19

The attempts of governments and other actors to steer communities, countries, or groups of countries in the pursuit of health as integral to wellbeing through both whole of government and whole of society approaches

Question 20

What does the global health governance involve?

Answer 20

• National governments
• Supranational bodies
• Nongovernmental organizations
• Cities
• Corporate sector
• Pharmaceutical industry
• Other sectors e.g., economy, the environment, education, housing, transport and the food system

Question 21

What does the constituency model of governance involve?

Answer 21

• Government in the middle is connected to:
• Private sector
• Private foundation
• Civil society
• People affected by health issues
• Multilaterals
• Bilaterals

Question 22

List the difference factors of good governance

Answer 22

• Accountable
• Consensus orientated
• Participatory
• Follow the rules of law
• Effective and efficient
• Equitabke and inclusive
• Responsive
• Transparent

Question 23

Complexity
What are the complex problems in health policy call for learning and adapting?

Answer 23

• Complexity, uncertainty, high stakes and conflicting value
• Systems thinking used to analyse problems and devise solutions
• Policies to be implemented as large scale experiments
• A commitment to learning from practice
• Monitoring and evaluation
• Policies adapted based on experience