Policy and Practice Towards evidence

Policy and Practice
Towards evidence-based health care reform
Mikko Vienonen1, Danguole Jankauskiene2 & Arvi Vask3
Health care reform in Europe is discussed in the light of the Ljubljana Charter, with particular reference to progress
made in Estonia and Lithuania.
Voir page 46 le résumé en français. En la página 47 figura un resumen en español.
In 1996 WHO organized a ministerial-level conference in Ljubljana, which was attended by 46 European Member States. On the basis of many years of
analytical work (1), they endorsed the Ljubljana
Charter on Reforming Health Care in Europe, stating
that within the European context health care systems should be driven by values (such as human dignity, equity, solidarity and professional ethics),
targeted on health, centred on people, focused on
quality, based on sound financing, and oriented towards primary care. Additionally, the Charter identifies as principles for managing change the need to
develop health policy, listen to the people’s opinions, reshape health care delivery, reorient human
resources for health care, strengthen management,
and learn from experience.
A sceptic might ask: “What is new in the
Ljubljana Charter?” The main thing is that this was
the first time that some elements of common knowledge about health care reforms had been presented
simply and clearly in an agreed statement at ministerial level. Very few politicians would have dared
speak out individually on these matters. Most socalled health care reforms have not focused on health
improvement at all, and in fact have made things
worse as far as the general public is concerned. Financial and administrative adjustments alone are not
enough if reform is meant to have the connotations
of improvement and betterment.
First and foremost, health care reform should
be about reforming health. This seems to be a statement of the obvious, yet health has been losing
ground in the profound political and economic
changes sweeping through Europe. In most countries the reforms have focused on cost-cutting, while
too little attention has been given to their longerterm effects on health.
1 Regional Adviser for Health Services Management, WHO Regional
Office for Europe, Scherfigsvej 8, 2100 Copenhagen Ø, Denmark
(tel: +45 3917 1203; fax: + 45 3917 1870; e-mail:[email protected]).
2 Secretary of State, Ministry of Health, Gedimino av. 27, 2600
Vilnius, Lithuania.
3 Head, Health Department, Ministry of Social Affairs, Gonsiori 29,
EE 0100 Tallinn, Estonia.
© World Health Organization 1999
What has worked...and what hasn’t
Health sector reform is multifaceted and multilayered. At one end of the continuum is the administrative and managerial quest for cost containment
to keep health care expenses within sustainable limits. At the other end is the individual citizen’s wish
to obtain the best possible care. These aspirations
may seem irreconcilable. However, as citizens ultimately pay for health services—whether public or
private—it is clearly in their interest that money be
spent in the most effective and efficient ways.
There is little evidence that cost-containment
strategies, focused on rationing, competition among
insurers, or co-payment, have positive economic effects (2). Furthermore, unless attempts to reduce the
demand for health services are accompanied by protective regulations, they may substantially diminish
people’s access to the services and thus threaten the
health of populations. Markets are amoral (3). One
of the drawbacks of health system markets is that
high-risk groups such as the elderly and chronically
ill can easily be identified and excluded. Strong public action is required if this is to be avoided.
The reforms that have been best able to improve health and reduce costs have concentrated on
changing the behaviour of the providers of health
services, namely health workers and hospitals. Reforms focused on the funders of health services, i.e.
patients, insurance agencies and the state, have generally been less successful. New managerial roles of
the state have emerged, including the assessment and
monitoring of the outcomes of reform. Reforms seem
to work best when implemented incrementally rather
than all at once. Evolution is better than revolution.
One of the most difficult questions is how to
involve the public in decision-making, which tends
to become remote from people’s everyday problems.
Every opportunity should be taken to facilitate dialogue so that decision-makers remain firmly in touch
with reality.
From theory to practice
The ability to achieve objectives in health systems
depends on the capacity of policy-makers to respond
Bulletin of the World Health Organization, 1999, 77 (1)
Towards evidence-based health care reform
flexibly and creatively to the policy environment they
confront. Cross-national learning about reform experiences is an essential element in this process, as is
the adaptation and adjustment of reform mechanisms to accommodate local circumstances. While
the basic principles of health reform are universally
valid, their application varies with each country’s
needs and expectations and with the understanding
of reform issues by politicians, health professionals
and society as a whole.
Particular difficulties have arisen in Central
and Eastern Europe and the newly independent
states of the former Soviet Union. A major contributory factor has been the deterioration of economic
circumstances, output having declined and with it
the tax base. Failing state enterprises and increased
demand for compensatory social expenditure has
exacerbated the fiscal burden on most transitional
economies. Strong social and economic pressures are
building up in many of these countries. The medical profession, moreover, has been very vocal in promoting changes that would strengthen the position
of doctors.
The pendulum continues to swing: dissatisfied with an initial position, policy-makers set out
to make fundamental changes, then move in the reverse direction as the shortcomings and problems
associated with the changes become apparent. The
countries of Europe are in various stages of this cycle. Several Western European countries are setting
out on major experiments. In Northern Europe,
where reform began, there has been a substantial
retreat from the most radical position, that of market-oriented incentives, towards the original position of publicly planned coordination and
cooperation. In some of the newly independent states
there is a tendency to compare today’s extremely difficult conditions with those of the Soviet period,
when the health systems as least functioned, and to
hesitate about how to proceed.
A health care reform laboratory
Being small can sometimes be an advantage. In spite
of economic constraints, the Baltic countries have
made remarkable progress in reorganizing their
health care delivery and financing systems. Mistakes
have been made, but in the light of them
reassessments have been made and corrective measures taken to the extent politically possible.
Estonia and Lithuania have received technical
assistance and material aid from major international
and donor agencies, and have been closely involved
in WHO networks and engagements, including the
analysis and preparation for the Ljubljana Conference and Charter. This has been an important factor, together with internal motivation and
determination, in both countries’ progress in health
development. They have not allowed themselves to
be unduly distracted from the main issues by the
plethora of actors who sometimes advocate and, inBulletin of the World Health Organization, 1999, 77 (1)
deed, seek to impose their own values and systems.
Estonian and Lithuanian health administrators and
planners realized at an early stage that copying others was not desirable and that quick fixes did not
exist. Thus, for instance, up to the present there has
been only a moderate degree of privatization of
health care institutions. Both countries have given
special attention to reform of health care delivery.
Lithuania has developed a strong national health
policy in collaboration with all major interest groups.
In addition to the measures taken in primary care,
public health and the pharmaceutical sector, a very
important principle was introduced for the remuneration of inpatient care providers, involving performance-related payment (4). This is intended to
be the main tool for increasing the productivity of
health care providers. Payments to hospitals are based
on a cost-per-case system, cases being classified in
50 diagnostic groups. The number of cases treated
is contractually agreed between each health facility
and the State Patient Fund, a newly established social health insurance system. There is a ceiling on
the total payments that the Fund can make, and if
the institutions increase their throughput of cases
the cost per case is proportionately reduced.
A new payment system has also been developed for outpatient services in Lithuania. In the first
half of the 1990s, there was strong support, especially from physicians, for adopting fee-for-service
remuneration on the German model. A need was
felt to increase physicians’ productivity, to improve
patient care, to reduce under-the-table payments,
and to increase doctors’ job satisfaction. However,
the economic recession and a dramatically reduced
public health care budget demonstrated the importance of financial affordability and the desirability
of concentrating on health promotion and health
education. WHO drew attention to the disadvantages of creating a payment system that rewarded
maximization of the volume of medical services
aimed at treating illness. The cautious approach was
strongly supported by WHO and tied in with the
principles of the Ljubljana Charter. A mixed formula
for payment of physicians was initially agreed on,
whereby about 70% consisted of capitation, based
on the number of people on the lists of doctors at
the first-contact level, and additional, clearly specified items were paid for on a fee-for-service basis. In
practice, however, a system based entirely on capitation was adopted in 1997, and the fee-for-service
component is expected to be introduced gradually
as the system develops. Time will show how well the
new scheme performs, but the focus on the delivery
side of services has a much better chance of success
than would be the case if the system were wholly at
the mercy of market forces. This transitional solution does not limit access to health care but does
contain and balance the health care budget.
Estonia has been very active in establishing a
functioning family doctor system. The Department
of Polyclinic and Family Medicine was set up in the
Faculty of Medicine of the University of Tartu, and
Policy and Practice
a two-year modular training course in general practice was introduced for polyclinic interns, paediatricians and surgeons who had worked during the
Soviet period. Some 300 family doctors have been
trained and 200 graduate annually. It is expected
that the country’s requirements in this area will be
met by 2002, when there should be 800 family doctors, i.e. one per 1800 inhabitants. A three-year residency programme has been developed in order to
sustain the pool.
In 1997 it was decided to set up a family doctor system throughout Estonia. This was important
in order to provide working opportunities for the
newly retrained family doctors. With the help of the
European Union and substantial WHO involvement, a comprehensive plan for rapid transition was
prepared. This consisted of registering patients with
individual family doctors, establishing a new remuneration system for the doctors, and defining the
profile of work and equipment needed. The aim has
been to put primary care at the forefront of the health
care system. The new arrangements underline the
role of the family doctor at the first-contact level.
Community care, health promotion and primary
care nursing still need to be strengthened.
In some parts of Estonia the secondary-level
polyclinics were hostile to the new system. However, the backing of WHO and the influence of the
Ljubljana Charter made it possible to proceed despite the opposition.
The strong backing of all European Member
States for the Ljubljana Charter has helped to return health itself (rather than economics and politics) to centre stage in the European debate on health
care reform. WHO’s Regional Office for Europe is
taking the lead in working with countries to build
their health care reforms, using the scientific and
ethical tools that have been jointly developed. The
renewal of the health-for-all policy at both the global and the regional levels can further strengthen
this movement if health care systems are seen as an
essential element and actor, indeed as a change agent
in the policy.
The policy pendulum, the difficulties of policy
transfer, and the lack of convergence should not lead
policy-makers to believe that health care reform is
futile or that effective solutions cannot be found.
The European experience and the outcome of recent supply-side initiatives have demonstrated that
health care reform can succeed as well as fail, can be
moderate as well as radical, can strengthen primary
care and equity as well as harming them, and can
reinforce the moral underpinnings of the welfare
state as well as eroding them.
About 20 European countries have already
chosen to publicize the Ljubljana Charter. Since
1996 the Charter and the analysis associated with it
have been used by health sector politicians, administrators, professional groups and grass-roots organizations in support of their arguments with ministries
of finance and, particularly, with proponents of unrestrained privatization. Even WHO is now in a better position to provide advice to governments on
these matters.
Some countries are clearly benefiting from
putting the Ljubljana Charter into practice while
others are not yet doing so. For WHO it is vital to
concentrate on the essential issues because the scarcity of resources does not allow action on a wider
front. The Charter can serve as a beacon guiding
navigators across difficult waters but is no substitute for an experienced crew and a sturdy vessel. ■
Vers une réforme des systèmes de santé fondée sur des faits concrets
En 1996, l’OMS a organisé une conférence ministérielle
à Ljubljana au cours de laquelle la Charte de Ljubljana
sur la réforme des services de santé en Europe a été
approuvée; cette Charte stipule que dans le contexte
européen, la réforme des systèmes de santé devait être
guidée par certaines valeurs (dignité humaine, équité,
solidarité et éthique professionnelle), être axée sur la
santé, centrée sur l’individu, inspirée par un souci de
qualité, être financièrement viable et orientée vers les
soins de santé primaires. Il est également ressorti que
la gestion du changement est en fin de compte l’épreuve
décisive de toute réforme. D’un côté, il y a cette tendance, dictée par des impératifs administratifs et gestionnaires, à réduire les coûts; de l’autre, il y a l’individu
qui souhaite obtenir les meilleurs soins possibles. Il ne
semble guère que le fait d’insister sur le rationnement,
la concurrence entre compagnies d’assurance ou le copaiement ait des effets positifs sur les réductions de
coût, et à moins d’être accompagnées de mesures de
protection, ces dispositions risquent fort de menacer la
santé des populations. Les réformes qui ont le mieux
réussi à améliorer la santé et à réduire les coûts sont
celles qui se sont attachées à modifier les comportements des agents de santé et du personnel hospitalier.
Les petits Etats de l’Europe centrale et de l’Est
sont devenus des «laboratoires de réformes du secteur
de la santé». L’Estonie et la Lituanie, deux petits Etats
baltes, se sont particulièrement concentrés sur la réforme des prestations de santé. La Lituanie a su se doter d’une politique de santé nationale efficace et a
entrepris des réformes touchant les soins de santé primaires, la santé publique et le secteur pharmaceutique.
Les sommes perçues par les hôpitaux sont calculées sur
une base forfaitaire par cas et la rémunération des généralistes repose sur la capitation, contrairement aux
recommandations des groupes de pression médicaux
qui étaient favorables à la rémunération à l’acte. L’Estonie a instauré un système national d’assurance-maladie obligatoire pour la population et non sélectif et
non concurrentiel pour les compagnies d’assurance. Le
médecin de famille est considéré comme le pivot du
futur système de soins de santé en Estonie, ce pays ayant
Bulletin of the World Health Organization, 1999, 77 (1)
Towards evidence-based health care reform
judicieusement mis en place des cours de formation
universitaire de haut niveau à l’intention des généralistes. Dans un deuxième temps, un réseau de médecins
de famille a été créé et une méthode de rémunération
motivante faisant appel au système national d’assurance-maladie a été mise en place. Les hôpitaux et les
polycliniques du niveau secondaire, hostiles à ce nouveau système qui menaçait leur autorité, ont tenté de
gagner le public à leur cause. Mais le Gouvernement
estonien est attaché à la réforme des soins de santé
primaires, et les réformes progressent avec le concours
de l’OMS.
Les exemples de l’Estonie et de la Lituanie montrent les difficultés pratiques que pose la gestion des
changements. Administrateurs et responsables politiques nationaux peuvent être largement aidés par des
instruments internationaux comme la Charte de
Lujbljana et aussi par l’analyse que l’OMS peut faire
des autres réformes en cours : un moyen pouvant atténuer les effets de balancier inutiles qui, régulièrement,
entachent les réformes du secteur de la santé des pays
de l’Europe centrale et de l’Est.
Hacia una reforma de la atención de salud basada en pruebas
En 1996, la OMS organizó una conferencia de nivel
ministerial en Liubliana que adoptó la Carta de Liubliana
sobre la reforma de la atención de salud en Europa, en
la que se declara que en el contexto europeo los sistemas de atención sanitaria deben estar guiados por valores (como la dignidad humana, la equidad, la
solidaridad y la ética profesional), enderezados a la
salud, centrados en las personas, focalizados en la calidad, basados en una sólida financiación, y orientados
hacia la atención primaria. También se llegó a la conclusión de que la gestión del cambio es la prueba decisiva de toda reforma. En un extremo de la cadena se
halla el empeño a nivel administrativo y gerencial por
contener los costos, y en el otro el deseo de cada ciudadano de obtener la mejor atención posible. Hay pocos indicios de que la insistencia en el racionamiento,
la competencia entre aseguradores o los sistemas de
copago tenga un efecto positivo en la contención de
costos, y de no estar acompañadas por reglamentaciones de protección, esas medidas pueden constituir una
grave amenaza para la salud de la población. Las reformas que con mayor éxito han permitido mejorar la salud y reducir los costos se han concentrado en el cambio
del comportamiento de los trabajadores de la salud y
los hospitales.
Los pequeños países de Europa central y oriental
se han convertido en «laboratorios de la reforma de la
atención de salud». Estonia y Lituania, dos pequeños
Estados bálticos, han otorgado especial atención a la
reforma de la prestación de asistencia sanitaria. Lituania
ha elaborado una sólida política sanitaria nacional y
reformado la atención primaria, la salud pública y el
sector farmacéutico. Los hospitales cobran según el
costo por caso y los médicos generalistas son remunerados por lo común conforme al sistema de capitación,
contrariamente al deseo de los grupos de presión médicos que propugnaban un método basado en el pago
por servicios prestados. Estonia estableció un sistema
de seguro nacional de salud que no permite a los aseguradores la opción de retiro ni la competencia para
apoderarse de las mejores partes de mercado. El médico de familia se considera una pieza fundamental del
futuro sistema de atención de salud de Estonia, que ha
comenzado a construirse a partir de la base adecuada,
a saber, estableciendo una formación universitaria de
alto nivel para los especialistas en medicina general.
En la segunda fase de la reforma, se creó una red de
médicos de familia y se instauró un sistema de remuneración atractivo mediante el seguro nacional de salud. Los hospitales y policlínicas de nivel secundario han
considerado esta evolución como una amenaza para
su antigua hegemonía y han tratado de ganarse al público. Sin embargo, el Gobierno de Estonia está comprometido con la reforma de la APS y, con el apoyo de
la OMS, las reformas siguen adelante.
Los ejemplos de Estonia y Lituania muestran lo
difícil que es en la práctica la gestión del cambio. Para
los políticos y administradores nacionales pueden ser
una considerable ayuda las declaraciones de consenso
internacionalmente acordadas, como la Carta de
Liubliana, lo mismo que los elementos concretos que
aporte el análisis de las reformas en curso que está
realizando la OMS. Esto puede atenuar el innecesario
efecto péndulo, que tan habitualmente acecha a las
reformas de la atención de salud en Europa central y
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services in Lithuania. In: Proceedings of a workshop
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