Year 1 Report on Mapping the Pathways to Universal Healthcare Project

Year 1 Report on Mapping the Pathways to Universal Healthcare project

Introduction

The Health Research Board Mapping the Pathways to Universal Healthcare project began in October 2014. The initial project plan committed to submitting a year one report on assessing and measuring the size of gap, recent progress and trends on universal healthcare in Ireland.

Specifically component one of the project set out to:

To assess the gap between the current Irish health system in terms of access and provision and the realisation of universal health care, using, evaluating and adapting WHO definitions and concept by

1. Specification of targets and indicators for the WHO dimensions of universal health coverage (package, coverage and user price/charge). Draft bundle of indicators by month 6;

Progress on this work in year one:

Initial work of the project reviewed the international literature on WHO definitions and concepts of universal healthcare. This involved gathering all relevant national and international documents which are stored in a database for project use. Most relevant documents are published on our project website International UHC documents and National UHC documents.

This work took the form of ‘A working paper on concepts of UHC and potential indicators for benchmarking Ireland (and other high income countries’) progress towards UHC’ drafted by project team members Sara Burke, Sarah Barry and Steve Thomas (appendix 1). It was presented to an international team meeting in February 2015 (including theEuropean Observatory on Health Systems), to our advisory group in June 2015 and at our seminar in September 2015.

While concepts and definitions are clear, there is little relevant literature on indicators for UHC in high income countries. Most of the literature is devoted to low and middle income countries and many of the indicators are focused on Millennium development goals.

The WHO conceptual universal health coverage around three distinct components –

1. The population – who is covered
2. The services – which services are covered and of what quality
3. The costs – what do people have to pay out of pocket for and does this cause financial hardship.

More recent WHO work in a higher income country context suggests a focus on

1. Financial risk protection
2. Health service coverage a
3. Equity.

Following discussions at our international team meeting and local advisory group, it was decided to collect indicators for Ireland under the following headline areas:

1. A full package of care matching need
2. Financial protection
3. Coverage for all
4. Resources for UHC (including financial and human resources and
5. Quality of care.

A five dimensional framework for analysis was developed around these areas – see page 8 of working paper.

1. Assessment from relevant policy documents whether the commitment to UHI and free GP care in the Programme for Government actually matches the WHO concept of universal health coverage as outlined by WHO and the experience of other countries that claim the achievement of universal health care. Brief report by month 9.

This work was progressed in year one when the initial assessment work was done on concepts and definitions of UHC. It was also presented to the international team for discussion, to the local advisory group and based on feedback amended and presented at the year one seminar. Instead of producing a brief report on this for year one, it was drafted a journal articles for Health Policy and published in December 2015 (see appendix 2).

1. Measure Ireland’s performance using the key indicators, assess recent progress or deterioration of these indicators and identify the size of the task remaining. Present gap analysis report to Local Advisory Committee (LAC), month 8, and at end year 1 workshop;

As stated above the conceptual work focused on five dimensions, for each of these indicators were suggested, often based on what was possible to collect rather than what was best. These were presented at our first annual seminar and initial indicators collected are on our website.

Significant work was done in Year 1 on financial protection as part of a new WHO Europe focus on universal healthcare and financial protection in a high income context. Financial protection is traditionally measured usingtwo indicators associated with the use of healthservices: impoverishing and catastrophic out-of-pocket payments. Both indicators estimatethe number of households in which out-of-pocketpayments for health care exceed a predefinedthreshold. In both cases, it is not the absolute amountof out-of-pocket spending that is important, but ratherthe impact that it has on household living standards.

We have carried out analysis using the WHO Europe new methodology for measuring Financial Protection with 2009/10 National Household Budget Survey. The findings were presented at our year one seminar where both the international and national research was presented. These findings will be updated and published by the WHO and the TCD team in 2017 when new 2015/6 data is available.

1. These indicators will be updated online and in policy briefs for the duration of the project.

As stated above, they are now on the project website and regularly updated.

Appendix 1

DRAFT working paper on concepts of Universal Health Care (UHC) and potential indicators for benchmarking Ireland’s (and other high income countries’) progress towards UHC

June 2015

Sara Burke, Sarah Barry, Steve Thomas

Universal Health Coverage/Care

Universal health coverage/care has its origins in the WHO 1978 Declaration of Alma Alta which stated:

Primary health care is essential health care… made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development... It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community (WHO 1978).

Such thinking has now largely evolved into Universal Health Coverage. According to the WHO, the ‘goal of universal coverage is for everyone to obtain the services they need at a cost that is affordable to themselves and the nation as a whole’ (WHO 2013: 7).

A recent World Bank report defined ‘the goals of universal health coverage are to ensure that all people can access quality health services, to safe guard all people from public health risk, and to protect all people from impoverishment due to illness, whether from out-of-pocket payments for health care or loss of income when a household member falls sick (The World Bank 2013): 10).

In 2005, all WHO member states including Ireland signed upto achieve universal health coverage. The UN General Assembly in 2012 and the WHO 2013 World Health Report reiterated the 2005 commitment to Universal Health Coverage (WHO 2005, WHO 2010, WHO 2013, WHO 2013). According to the WHO and UN, Universal Health Coverage achieves better health outcomes for individuals and whole populations because accessing services is not inhibited by cost(WHO 2010, WHO 2013, WHO 2013).

WHO uses a cube to demonstrate the three facets of Universal Health Coverage (UHC) as specified below, also sometimes referred to as the breadth, depth and height of coverage. See figure 1 below. Nevertheless, it is unclear whether these three dimensions do justice to the rich concept of UHC and this is a matter that the authors return to later.

Figure 1: Dimensions of Universal Health Coverage, WHO

Indicators for Universal Health Care in the Existing Literature

There is much reference to the need for research and to develop indicators of UHC in WHO documents since 2010, but few if any of them give potential examples for high income countries, apart from the headline areas of 1) financial risk protection and 2) health service coverage and 3) equity. The fact that there are few examples of indicators for high income countries may suggest that there is little clarity around what UHC means in a high income context. Without clear definitions, it is difficult to know what is to be measured.

The WHO/World Bank further recommend country specific monitoring of UHC reflecting each country’s unique epidemiological and demographic profile as well as population demands, the type of health system and levels of economic development. While there is wisdom in this approach to making indicators useful in a specific context, it avoids the issue of precise definition. Their selection criteria recommended are:

• Relevance – Do the indicators measure conditions of priority health needs? Is the service cost-effective? Is the service a source of major health care expenditure?
• Quality – Do the indicators measure effective or quality-adjusted coverage?
• Availability – Are the indicators regularly, reliably, and comparably measured (i.e. numerators/denominators/equity stratification) with existing instruments (e.g. household surveys or health facility information systems)? (WHO/The World Bank 2013).

Where the WHO/World Bank do develop indicators they tend to be derived from the Millennium Development Goals and are largely irrelevant to high income countries.

Unpacking the elements of UHCand potential indicators

In the following sections the authors unpack a much fuller definition of UHC pointing to areas where indicators are needed if progress is to be measured before relating such measures to the Irish context.

1. A full package of care matching need

A key question for any country attempting to implement UHC is exactly what care should be supplied. If there is to be universal access for a population to health care, what entitlement does that bring? Clearly universal access to long waiting lists for poor quality care, resourced by understaffed facilities and demotivated staff, is not an achievement worth celebrating.

The definitions from WHO and the World Bank imply “a full spectrum of quality health care” for all in need. This is a rich concept and there are several elements to this which need to be unpacked.

First the needs of the population have to be understood. This requires both an understanding of the demographic profile and the most prevalent conditions and the services which are required to match the needs. This in turn necessitates a supply capacity appropriately resourced (finances, human resources and physical infrastructure) which reflects and is responsive to need. Hence the system has to have the right capacity in place. (This is dealt with in section below on resources).

Second, the care provided must be appropriate, proportionate and according to clinical protocol/best evidence and provided by the right health professionals.

Third, the appropriate placement and location of care is critical. Universal access will mean that there are no geographic blackspots in coverage for a particular service or that the time for accessing critical services is broadly even across the country and within an acceptable range.

Fourth, the presence of waiting lists indicates a mismatch between supply and demand. The majority of people on waiting lists deteriorate and long waiting lists lead to increased morbidity and mortality and are not a feature of UHC. If care is needed, delaying care by placing people on an extended waiting list does not appear to square with a needs based approach for all. Careful targets are required for maximally acceptable waiting lists. In order to measure this mismatch between supply and demand, the best and worst waiting lists per specialty and hospitals can be looked at for OPD, daycase and inpatient treatment. It would also be useful to look at access to primary and community services.

To measure the ‘full package of quality care according to need’ requires good, timely data on

• Demographics – pop size, age profile, health status, mortality, morbidity, burden of disease
• Measuring ‘appropriate, proportionate care according to clinical need’ is not straight forward especially given the early stage of clinical protocols and integrated care pathways in Ireland. The pathway of a patient through a health system and the coordination between different facilities and services is telling of health system performance. UHC is not a guarantee of all care at all levels but the most appropriate care at the appropriate level. It must also stipulate something about the ease of transfers between one part of the system and another when medically appropriate. Possible indicators include the existence and or use of clinical protocols in specific clinical care programmes.

This year the HSE has committed to Integrated Care Programmes for Patient Flow; Children; Maternity Services; Older People; and the prevention and management of chronic diseases.

Monitoring these could be possible indicators of appropriate and proportionate care according to clinical need (HSE 2014).

• Geographical access to healthcare – is measuring geographical distance to certain facilities eg GPs, ED, trauma centre, stroke care, cancer services, differences in ambulance response times?
• Matching supply and demand – waiting lists are an indicator of demand outstripping supply but are largely based on hospital care due to data availability, however, measuring access to primary and community care services is equally important and may begin to be possible as the HSE has started collecting indicators on these.

Available indicators for the package of care / Source
1 / Population size / CSO
2 / Population growth and trends (whole pop over 65s) / CSO
3 / Perceived health status
4 / Morbidity
5 / Prevalence of chronic diseases
6 / Life expectancy ( & over 65s)
7 / Mortality rates
8 / Numbers of clinical protocols developed
9 / Numbers of clinical protocols implemented
10 / Distance to local GP – rural areas, urban deprivation areas
11 / Comparing ambulance response times
12 / Waiting times for initial outpatient appointment (best and worst by specialist and hospital/group location? / HSE PR
13 / Waiting times for day case treatment – adults (best & worst) / HSE PR & NTPF/SDU
14 / Waiting times for day case treatment – children (best & worst) / HSE PR & NTPF/SDU
15 / Waiting times for inpatient treatment – adults (best & worst) / HSE PR & NTPF/SDU
16 / Waiting times for inpatient treatment – children (best & worst) / HSE PR & NTPF/SDU
17 / Nos waiting for ED admission (best & worst) / Trolley watch
18 / Nos waiting for ED admission - over 9 hours (best & worst) / SDU/Trolley GAR
19 / Nos waiting for ED admission - over 24 hours (best & worst) / SDU/Trolley GAR
20 / Waiting times to access Child and Adolescent Mental Health Team / HSE
21 / Primary care – longest waiting time for eye care, psychology / HSE
22 / Primary care – longest waiting time for child orthodontics / HSE
23 / Primary care – longest waiting time for podiatry, audiology / HSE
24 / Primary care – longest waiting time for dietetics, nursing / HSE
21 / Percentage of physiotherapy referrals seen for assessment in less than 12 month & treatment in less than 2 years[1]

1. Indicators for financial protection

UHC clearly implies that households should not be impoverished by out of pocket payments for healthcare or face catastrophic out of pocket payments for their health care (WHO 2014). Nevertheless, it also seems from the World Bank paper that UHC actually implies no direct payment for health care which means in all probability no out of pocket payments for health care access[2]. User fees themselves tend to produce inequity of access as some households will be put off seeking care by the financial barriers. They are also a poor mode of rationing, a blunt instrument, in that they prevent as much necessary as unnecessary use.

The two main forms of private spend on healthcare in Ireland are out-of-pocket payments to see a health professional and for drugs and premia paid for private health insurance. Given the shift in health expenditure in Ireland over recent years from the State onto people, evident in new and increased charges for hospital care and drugs, as well as the shifting landscape in terms of numbers covered by private health insurance and paying for GP care, it is worth monitoring these specific spends to see if they impact on financial protection or not over time (Thomas 2014).

Indicators for financial protection / Source
1 / Public private spend / OECD/WHO
2 / Private health insurance spend / HIAI/HBS
3 / Out of pocket spend / OECD/WHO
4 / Incidence of catastrophic health expenditure / HBS/EU SILC/QNHS
5 / Incidence of impoverishment from health expenditure / HBS/EU SILC/QNHS
6 / € spent on drug charges for GMS (medical card holders) / HSE PCRS data
7 / € spent on drug payment scheme / HSE PCRS data
8 / € spent on public hospital bed charges / HSE PR activity & income data
9 / € spent on ED charge / HSE PR activity & income data

1. Coverage for All

It is important that the entitlement to care without financial barrier extends across all sections of the population regardless of age, gender, household income or any other socio-economic variable. It is also important that the differential ability to pay of some households does not translate into them getting access to faster or better medical care than those who cannot to pay. Therefore measuring and monitoring over time the numbers included in the medical card scheme (GMS), free GP care, those covered by private health insurance and universal schemes within the public health system are good indicators of coverage.

Indicators for coverage / Source
1 / GMS (Medical card) coverage / HSE PR & PCRS data
2 / Free GP care / HSE PR & PCRS data
3 / Private health insurance coverage / HIAI
4 / Maternity & infant care scheme / HSE
5 / Immunisation rates / HSE
6 / Screening rates (breast cancer, cervical, bowel) / HSE

1. Resources available for UHC

Given scarcity of resources is an endemic feature of all health systems, it is important to consider how this is best managed. Not all services should be provided at all facilities free of charge without gatekeeping (e.g. access to outpatient specialist appointments requires GP referral in the public system). Therefore key decisions need to be made if UHC is to become a reality or at least to become a nearer reality. Furthermore, user fees or market based rationing is generally considered to be ruled out with a UHC based approach because of the risk of differential access or just barriers to access for some. Still, resource scarcity means that other forms of rationing will need to be implemented.