Tim Tenbensel Revital Gross

Introduction: Policy innovations

Definition – policy innovation – a new strategy or approach to achieve health system goals

Includes a variety of measures: statements e.g. proposals, legislation, incentives, structural change, monitoring/evaluation

We refer to policy innovations initiated by government which have a system-wide impact

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The questionsIn what ways does the mode of funding health

systems (taxation or social insurance) affect:The health system objectives that innovations

address? Access & equity, efficiency, quality, population health

The nature of the tools for change (policy instruments) used? Christopher Hood’s NATO scheme for all policy issues

(N)odality (information); (A)uthority (legislation); (T)reasure (additional funding); (O)rganisation (structure)

Other policy tools (changes to) responsibility for paying for health services;

workforce initiatives; technology; standards & targets; research

Importance of topic Theoretical value:

Although comparisons between health systems have been conducted, the implications of differences for policy innovation have not been formerly explored

Our analysis will help in developing a conceptual framework for future studies on this topic

Practical value: Analysis may help to indicate which innovations

are less ‘context-dependent’ and therefore more amenable to transfer

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Why might we expect differences?

Structure of health systems affects many parameters

- (e.g. incentives to providers, costs, quality of service, service delivery, power structure); reasonable to assume it will also affect process of policy innovation

Systems shape the capacity of policy actors to act

- ability/power to change- different access to resources needed for change- reasonable to assume this will lead to differences in the

process of policy innovation (which is a change process)

Path dependency- Historical, institutional & cultural circumstances that

shaped system may have similar effects on other system features including policy innovation

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Why might we expect similarities?

Objectives of access / equity, efficiency, quality and population health are not context-dependent, they are widely shared

All governments have a similar range of policy instruments at their disposal

Universal trends - countries learn from each other

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MethodAnalysis of innovations reported by network members

of the Bertelsmann Foundation Health Policy Monitor (HPM) in the years 2003-2007

six countries chosen:Canada, New Zealand, Finland (taxation)Israel, Netherlands, Switzerland (social insurance)196 policy innovations reported

Innovations proposed by non-govt actors excluded Reports of the progress of previously reported innovations

excludedFinal dataset of 137 innovations (87 from tax-funded

systems, 50 from social insurance funded systems)7

CodingHealth system objectives –

5 values Access and/or equity Efficiency Quality Population Health Other

For both variables, cases may have more than one value for each variable

Tool for change (policy instrument) – 7 values Additional Funding Legislation / regulation Payment mechanisms Organisation / structure Information / research Standards / targets Workforce / technology

LimitationsThe HPM database does not include

all innovations in each countryMember countries can only report 10 initiatives per

yearReported innovations may not be representative of

country’s innovations.Selection of cases is not large enough to rule out

the effect of other relevant variablesPolitical complexion of governments5 years may not be long enough to capture variety

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Health system objectives

Access (including equity), in most but many more initiatives reported in tax-funded systems

Efficiency in all, but many more examples in social insurance systems

Quality-related innovations prevalent in all countries

Population health outcomes in most; many in NZ

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Possible explanationsFinding that social insurance systems concentrate

more on efficiency is plausible (a more pressing problem?)However, tax-funded systems have greater leverage

Tax-funded systems more interested in access & equity ( because they can influence this more directly?)

Influence of political complexion of governments (2003 -07) cannot be ruled out (all SI countries had centre-right govts in this period)

Time period is significant (both Canada and New Zealand were highly focused on efficiency in 1990s)

Tools for change (policy instruments)

Tools for change (policy instruments)

Tool for change by country

Tool for change by country

Tool for change Additional funding – mainly in tax-funded systemsChanges in payment responsibility – mainly in social

insurance systemsLegislating - in all to varying extents

Difference in systems mainly accounted for by difference between Switzerland and Canada

Structural and organisational change - in all except Switzerland (but may refer to different ways of restructuring);

Workforce & technology: in all countries except Switzerland

Standards & targets: in all countriesInformation & research: in all countries except Netherlands

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Possible explanationsAdditional funding & changes to payment responsibilityIn tax-funded systems government is responsible for services;

may lead to a greater incentive to allocate extra funding. In social insurance systems providers are responsible;

government can demand more with existing funding levels. Government has less control on use of funds and thus reluctant to

provide extra funding. In social insurance systems governments tend to propose ways

of cost-shifting to reduce government expensesIn tax-funded systems, costs can only be shifted to patients

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Possible explanationsLegislation

Switzerland’s pervasive use of legislation, and Canada’s light use of legislation are both due to particularities of federalism Switzerland: legislative process more central to co-

operative policymaking between national level and cantons

Canada: provinces have legislative responsibility for most health system matters Federal/provincial tensions likely to be resolved

through additional fundingIn other countries, only a small difference in

propensity to use legislation

ConclusionType of funding appears to influence

Some tools for change (not surprisingly, those related to funding and payment)

Type of funding may influenceBalance of health system objectives (but we

cannot rule out effect of governing parties)Type of funding appears not to influence

Degree of emphasis on qualityPropensity to use policy instruments not related

to funding