Reforming outdated health systems / Béatrice Majnoni d'Intignano

Reforming outdated health systems by Beatrice Majnoni d'lntignano hat is the best way of arriving at a compromise between equity and efficiency in health care? The countries of western Europe and Canada have reached this . goal by principles of: - Compulsory health insurance, with the. State taking responsibility for the poorest people. - Direct or indirect control of health expenditure by the State so as to ensure the right balance between costs and quality of care. - Each individual contributing accord- ing to his or her means, but also paying for health care according to his own wealth. This philosophy is radically different from that of the USA where-with the exception of the poorest and the elderly, who are covered by the Medicaid and Medicare systems- people are left to insure themselves, and where 35 million people are not covered at all despite the large amounts the nation spends on health. In northern Europe-in such coun- tries as Denmark, Sweden and the United Kingdom-the health systems stem from the Beveridge Report of 1942, drawn up by the founder of the British "Welfare State", Lord Bever- idge. The principle of an individual "capitation" requires family doctors to filter access to specialized health care and to receive a per capita fee. This is not a salary, as many people believe, but consists of sums paid to the general physician according to the number of patients who inscribe them- selves on his list and then receive health care free of charge. Other fixed sums are involved in this system, for instance to encourage doctors to work as a group practice, to practise in deprived areas , or perhaps to complete their training. Such activities as the first consultation, night visits, and contraceptive advice are paid for separately, and so are private consul- tations which the patients pay from their pockets. In central Europe, particularly Ger- many, Austria and the Benelux coun- tries, the health systems adopted may be called Bismarckian, after the 19th 6 century German Chancellor, because they evolved from the first German laws on sickness insurance, passed in 1893. Health care here is financed from professional contributions, and is controlled by those who represent the insured individual. Medicine is avail- able to all and is paid for according to the services used. Physicians who are paid "a fee for service" work harder, devote more time to each of their patients and earn more because they tend to stimulate an increased demand for their services. As a result, in countries where surgeons are paid · for their services, people have twice as many operations as people in countries where surgeons are paid a salary. As for technical interventions, these have sometimes become virtual money-making machines, as in the case of electrocard- iograms or echography during pregnancy. Payment according to the services has created a very active medical system oriented towards curative care rather than preventive action, based on the diagnostic, therapeutic, prognostic triad; its philosophy tends to be to take medical action rather than not to act. All the health systems in these "liberal" countries are at pains to make ever more precise diagnoses, even where truly effective treatments are lacking, and they still apply such treatments as they have, particularly when they are dealing with people of very advanced age. Countries of the east The countries of eastern Europe have their own national health systems, but a certain malaise has crept in because the doctors are officials of the State. They work less than doctors in western countries, and are more ready to sign sickness notes for their patients or order them to hospital. By giving their doctors a salary but only a low one, and by treating them as heirs of the bourgeois classes and therefore non-productive personnel, these coun- tries have sapped them of motivation. Health care is in principle free, but pharmaceuticals are practically unavail- able. Owing to shortages of contracep- tive pills in most polyclinics, abortions have become more frequent than births. Sickness notes to give people time off work, as well as the services of the few really competent surgeons, are paid for "under the table". In the USSR, it appears that legal health cooperatives represent 3-4% of the expenditure on health care, but the kickbacks could amount to eight to ten times more. The eastern countries only devote a tiny part of their gross national product to health: 3% in the USSR and 2.5% in Romania, compared to 7.5% in the countries of the Organization for Economic Cooperation and Develop- ment and 12% in the USA. As a consequence, medicine has come to be equated with "inequality and ineffi- cacity", and the attempt made by the USSR in 1985 to improve the situation by increasing the doctors' salaries by 30% ended in failure. Everybody ought to have access to medical services, whatever method is chosen for financing health care. The demographic indicators testify to the scale of the disaster. Expectation of life in USSR, Czechoslovakia and Hungary, which used to be compar- able with that of the western countries in 1970, is today some five to eight years less. In Romania, infant mortality ranges, from one area to another, from 17 to 50 per 1000 live births, compared to 7 in France. Health in the time of perestroika It will take decades to put this situation right, and medicine as a whole will have to be reorganized with the support of a healthy economy. From 1988 onwards, the USSR chose to introduce an experiment in free market mechanics and financial incentives into the national health system, which it wants to preserve. The polyclinics in St Petersburg (formerly Leningrad) will henceforth receive an identical per capita fee (75 to 100 roubles) for each citizen in the zone which they serve, and from this they have to deliver health care free of charge, either directly or by paying for hospital services. The hospitals no longer receive a budget but rather an advance payment, and they then have to sell their services according to a fixed tariff: 17 roubles for an abortion, 550 roubles for orthopaedic surgery and so forth. In certain cases where treatment fails, the patient may be taken into the hospital again without having to pay a second fee. The benefits of the new system are already being felt. The length of stay in hospitals has fallen, in St Petersburg dropping from 17 days to 12 days in the space of a year. The polyclinics seem to be accepting more responsi- bility and are obtaining equipment so that they can undertake minor surgery. The Fiodorov eye surgery centres are even going so far as to pay their surgeons "for each eye cured"- hoping in this way to reduce the numbers of failed operations and infections. The other countries of eastern Europe have adopted a different approach. The doctors there are often agents for change themselves. Fasci- nated by American liberalism in medi- cine, they have rejected the national system and cheerfully confuse the effects of liberal mechanisms with that of the wealth of the western clientele. The World Bank and WHO have sounded a warning that universal access to health care and controlled budgets are put at risk because of the wish to get rid of bureaucracy and mediocrity. WORLD HEALTH. November-December 1991 The financing of health cannot be reformed without · fiscal and salary reforms. The real question is to know whether it is best to continue paying fixed salaries, subject to the arbitrary ways of state bureaucracy, or to step up salaries in the health sector and create sickness insurance schemes so as to engage the general public in a process of responsibility, individual choice and democratic control of health expenditure. How otherwise can the present system of kickbacks be Eurohealth: a project for eastern Europe Europe is at present undergoing pro- found and . in some cases. d rast ic changes. Politica l. economic. socia l- no sector is spared . The hea lth sector in Europe had already been under critic ism- partly because it was becom- ing too expensive. partly because of ineffi ciency. People were becomi ng disenchanted. In some overly centralized and bureaucratic systems there was little room for public part icipati on- just at a time w hen people were becoming more and more aware of the importance of hea lth and more and more eager to take responsibility for their own health. The Eurohealth project was developed to contribute to the health ca re debate of the 1990s in Europe and more speci - fi cally to cater to the needs of the countries of centra l and eastern Europe. where the debate about the fu ture of thei r health care systems is particularly lively. The aim is to collaborate with coun- tries in developing new and more appro- priate hea lth po li cies. t o promote innovative action in loca l communit ies. and to improve the organizat ion. man- agement and financing of health care. The project also seeks to improve the hea lth informat ion systems and the tra ining of health w orkers. Research into ways of improving the situation is also regarded as an urgent pri ority. Contributed by Or Constantino Sakellarides. Director. Division of Health Services. WHO Regional Off ice for Europe. Copenhagen. One objective of the health services must be to oHer high-quality care. turned into a legal one, and how can doctors be persuaded that other forms of payment would be more ethical? The health systems of eastern Europe do not need to fall into the same traps as those in the West, which were conceived at the end of the 19th century or after the Second World War. Perhaps they will avoid the pitfall of certain professional health insur- ance schemes, where the ratio between the number of contributors and the number of beneficiaries can sometimes be catastrophic, and will instead prefer freely chosen health insurance options. By contrast, the example of the West ought to encourage them to prefer the European philosophy to that of the USA, to experiment with per capita fees for their family doctors, to ensure that their insurance schemes and their doctors have more respon- sible representatives than trade union officials, and to use payment mechan- isms better adapted to their true objectives-namely equity , full employment, and doctors' social status. The new philosophy of being able to shop around for the best available health insurance, public as well as private, ought to interest them as a first priority. Recent experiences in Europe have confirmed that it is financial incentives that shape the behaviour of doctors- hence the interest in choosing those · incentives well. • Professor Beatrice Maj- noni d'lntignano is a Pro - f esso r a t t he P a r i s- X 11 Unive rsities. Her address is 12 ru e Debe ll eyme. 75003 Pari s. France. 7