The Evolution of HTA in Emerging Markets Health-Care ... - TREE

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OHE Consulting Report for PhRMA 5 January 2011 5 Health Systems Categorisation 5.1 Literature search strategy In this strand of the work programme, we focussed our attention on categorization of healthcare systems to help us understand the roles of healthcare payers – distinguishing between single national/public payers and multiple private payers/insurers – and the role of doctors and patients in the final choice of treatments and/or management of diseases. For this purpose, we conducted a number of literature searches by exploring specific websites, such as Yahoo, Google, WHO, the European Observatory, OECD and the World Bank. A PubMed search has also been conducted using the following key words: ("health care systems") and (classification OR taxonomy OR categorisation OR categorization OR taxonomies), these results were then narrowed down based on the title, excluding papers which were disease specific. From the relevant literature identified, we identified various methods by which healthcare systems can be categorized depending on the objective of the analyst(s). We collected a number of publications which refer to health care systems classifications; however, most of these are mainly descriptive with a limited number providing a specific typology. However, from the literature examined, it is apparent that one can focus on the various functions of the component parts of health systems, the overall goals of health systems and the various functions affecting health system performance. Some publications mentioned factors which may indicate the ‘progression’ of a health system or systems, such as, the balance of trade for pharmaceuticals and health care products (see for instance, Banta and Almeida 2009), whether the system was centralised or decentralised (Byrkjeflot and Neby, 2008), and more specific elements such as a classifications based on career pathways (see for instance, Lawrence 2005). Other papers provided a framework for classifying best practice in healthcare (see for instance, Perleth, Jakubowski and Busse [2001]). In all, we note that there are various frameworks and taxonomy, each of which has been developed in ways to fit various objectives. We provide below a distillation of analytical frameworks and healthcare systems categorization systems that we deemed as the most relevant to this stream of the work programme. 5.2 Types of healthcare payers (insurers) One of the first widely recognized attempts to classify healthcare systems is Kutzin’s (2001) framework for classifying healthcare purchasers (or more generally insurers). Under this framework (see Figure 1 below), healthcare purchasers are classified as ‘single payers’ if there is one purchaser or there are multiple purchasers but covering geographically distinct populations. When there are multiple purchasers who do not cover geographically distinct populations, one has a ‘multiple payers’ system. In such a multiple-‐payer system, healthcare purchasers could be competing or not depending on the system for patients’ demand for health insurance and medical care. Kutzin (2001) notes that the issue at hand is not what is the theoretically best structure for healthcare financing and/or provision (i.e., whether it is a single-‐payer or otherwise) but rather, 24
OHE Consulting Report for PhRMA 5 January 2011 given the existing institutional arrangements, what is the appropriate direction for policy changes that will facilitate the functioning of health systems in ways that are publicly accountable, or at least, accountable to the population covered by each healthcare payer/purchaser. Irrespective of whatever is considered ‘theoretically best’, the starting point for policy analysis and reform in any particular country is the existing system. Figure 1: Framework for understanding healthcare purchasers/insurers: Kutzin (2001) 5.3 Functions of health systems Related to Kutzin’s (2001) work is Murray and Frenk’s (2000) framework for assessing health system performance. Although, this framework doesn’t actually offer a taxonomy of healthcare systems, it is useful tool for understanding the varying differences between healthcare systems in terms of four functions that all healthcare system perform irrespective of their heterogeneity and of differences in underlying philosophical and economic rationales for health system design. The four functions of healthcare systems are depicted below in Figure 2. Note that this framework is the same one used by Mossialos, et al. (2002) in the monograph “Healthcare funding options in Europe”. The four functions of health systems are: (1) Financing (2) Provision (3) Stewardship, and (4) ‘Resource’ generation. Given the importance of this framework we set out below more detail on the individual components. Financing: There are three dimensions to this: (1) revenue collection (2) fund pooling and (3) purchasing tasks. Revenue collection refers to mobilization of needed finance for medical care provision. Pooling refers to the extent of any redistributive and insurance element of the system in which revenues are collected in ways that ensure fairness in financial contribution and used in a way which provides health insurance protection. Purchasing refers to the process by which revenues collected are transferred to healthcare providers for the provision of medical services. It can be passive (for example meeting fee-‐for-‐service claims from providers) or active (agreeing what will be bought and negotiating payments with providers.) In between could come purchasing tasks such as 25
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