Health Care Delivery
· Key international trends:
o Changing demographics: esp elderly
o Communicable ® non-communicable diseases
o Concern with economy given rising costs
o Who should pay: public vs private
·
Issues in service delivery:
o Institutional arrangements:
§ Output funding
§ Priority setting
§ Funder/provider splits
§ Managed care
o „Cultural‟ issues:
§ Competition vs cooperation
§ Control vs community voice
§ Management vs technology
·
Influences on NZ history:
o 19th century legacy:
§ Parochialism (isolation ® self-government)
§ Adhocracy (new problem ® new organisation)
§ Egalitarian myth: services by right
·
References: Introduction to the
New Zealand Health System, Peter Crampton and Anne Viccars, Departments of
Public Health and General Practice, Wellington School of Medicine
·
Factors facing health systems in
developed countries:
o Ageing populations
o Medical technology
o Rising expectations
o Treaty of Waitangi
·
Health Care expenditure in New
Zealand:
o 1998 total: around $8 billion. Vote health was $5.6 billion in 97/98.
o 7.6% of GDP (compared with Australia 8.3% and UK 6.7%)
o Public 77%, private 23%.
o 18% of total government expenditure.
o Proportion of people covered by health insurance has declined since
1994/95
·
Health Legislation:
o Health and Disability Services Act 1993 (now repealed)
o Health Act 1956: main piece of public health legislation
·
Health Policy Agencies:
o Ministry of Health
o Other central agencies: Te Puni Kokiri, Treasury, State Services
Commission
o Other advisory bodies:
§ National Advisory Committee on Health and Disability (National Health
Committee)
§ Mental Health Commission: established in 1986 following Mason Inquiry
§ Health and Disability Commission: established in 1994 – responsible for the Code of Health and Disability Consumers‟ Rights
§ Health Sponsorship Council: Established under smoke-free environments
Act 1990 to sponsor activities previously sponsored by tobacco companies
·
Purchasers: Used to be the HFA, including
Pharmac and Health Benefits Limited
·
Purchaser-Provider Split:
o Potential benefits were:
§ Efficiency: due to competition
§ Equity: reflect need not historical provision
§ Accountability clearer
§ Cost containment due to capped budgets
§ Consumer sovereignty
§ Better information
§ Improvements in primary care: IPAs and Maori services
o Problems:
§ Short term market lead decision making
§ CHE debt/missed business plans
§ Transaction costs ® bad contracting relationships ® 3rd party intervention
§ Asset specificity: providers locked in ® little
real competition
§ Fragmentation of services
§ Loss of co-operation
·
Primary Care:
o Numbers:
§ 2,800 GPs (about 2,500 FTEs)
§ 1,600 practice nurses
§ 1800 – 2000 practising midwives
o Funding:
§ GP income derived from: Subsidies (depending on patient age and
CSC/HUHC), patient fees,
§ ACC
§ Primary Care Expenditure: 59% pharmaceuticals, GMS 15%, labs 13%,
maternity benefit 8%
o Themes: managed care, budget holding, integrated care
·
Latest reforms:
o Ministry of Health and HFA merged
o 21 District Health Boards created (roughly around old Hospital and
Health services): have a purchasing and a provision function
o Maternity providers funded by MoH
o DHBs fund NGOs, GPs, Private providers, public health providers
o ACC continues direct purchasing from primary and secondary providers
o Key changes:
§ No purchaser-provider split
§ Community control
§ Budget tension between primary and secondary services forced down from central agencies to DHBs
§ 21 Boards too many: diseconomies of scale
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