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Challenges facing the adoption of SHI in Ireland Dr Steve Thomas Centre for Health Policy and...
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Challenges facing the adoption of SHI in Ireland
Dr Steve ThomasCentre for Health Policy and
Management, Trinity College Dublin
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Objectives
• To review• What SHI is and rationale• Emerging Models for Ireland
• To highlight
• Key Obstacles & Challenges
• Perceived vs Real
• To reflect on the way forward
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SHI – Basic Features
• Insured persons pay a regular contribution based on income or wealth.
• Access to treatment and care is determined by clinical need and not ability to pay.
• Contributions to the social insurance fund are kept separate from general budget funds
• The social insurance fund finances care on behalf of the insured persons (pays public and private providers).
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Why SHI for Ireland
• No-one likes what we have• Only Few Financing Options
– Free Market - Afghanistan– Tax based - UK– Private Insurance – America, The Netherlands– Social Insurance – France, Germany
• Selling points SHI: Earmarking/Transparency, Contracting/Incentives, Universality, Resilience?
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Competing Models?• Fair Care - Fine Gael
Dutch Model – Universal multiple fund private insurance model
• Adelaide SocietyUniversal Single Fund (Non-Government &
Not for Profit) model• Labour (under consideration)
Universal Social Insurance model (April 2010 floated multiple funds + public insurer)
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Obstacles (Perceived and Real)
1.Resource AvailabilityContext - Economic CrisisIncreased Running CostsFinancing mechanisms
2.System Capacity– Physical Infrastructure– Human Resources– Architecture and Interactions
3.Politics
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The impact of the economic crisis on the prospects for SHI?
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Context: Economic Crisis
Threats
– Constrained resources (taxation collapse, debt servicing)
– Service cuts/reductions
– Morale loss through lower pay and service cuts
Opportunities
– Need for reform highlighted,
– Efficiencies made possible (some already in effect),
– Stakeholders more amenable to reform
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Additional Costs
• Adelaide III (2010) - additional cost of SHI • For the “Levelling Up” Model:
• Free medical cards for all • As if private insurance for all
• 3.1% extra costs with modest efficiency gains (recession windfall)
• Bail-out legacy - costs likely to decrease further • Verdict: Case not proved
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Financing Mechanisms
For multiple fund models…• Risk equalisation important• But … complex, costly and imperfectFor “pure” models…• Tax rebate important• But in Ireland size of rebate bigger than income
taxVerdict: Problematic but not overwhelming
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Capacity Constraints - Provision
• Need extra supply to match increased demandBUT1. Human ResourcesLow ratio of GPs to populationLow number of consultants
2. Physical InfrastructureAcute Hospital occupancy rates excessively high in
Dublin and MidlandsAbsence of Primary Care Facilities
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Capacity Constraints – Provision II
Acute hospital capacity:May be less of a problem IF efficiencies can be
made and Primary Care system much improved
Biggest problem:Human Resources 1. It takes time to train people2. EmigrationResponse: Skill mix issues (nurses, pharmacists),
Importing/Retaining
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System Governance Capacity
Shift to a Contracting ModelNew and adapted institutions (Funds,
hospitals)New ways of relating (Activity-based funding,
regulation) Government has primary role in designing SHI architecture, monitoring, defining benefit package and legislatingSystem requires strong management and information flows
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Acceptability and Stakeholders
• Understanding of ConceptComplexity On the doorstep
• Stakeholder DynamicsSupport vs Opposition
Providers (Public and Private), Civil Servants, Politicians, Civil Society,
Building Coalitions
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Conclusions
SHI has advantages...
But can't be achieved overnight (5-10 years)
Several obstacles: HR, system workings, opposition
Surmountable if
1. We take action now
2. The economy picks up at some stage
3. We have the heart for change
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The End
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Adelaide Report 4 – Policy Analysis
To identify whether the concept of SHI is understood
To identify and understand stakeholders'views and values about health financingpositions towards SHI power to influence change
To identify the perceived technical and political strengths and weaknesses of SHI
To develop strategies for taking forward SHI
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What do we need from any financing system?
Raising revenue – steady, predictable, sufficient
Sharing risk/solidarity – the larger the risk pool the better
Protecting the poor – subsidy & no “hidden” taxation (charges for services)
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TCD Programme of Research on SHI
Series of Adelaide reportsReport 1: Concepts, Design, Cost and
Contribution (2006)Report 2: Cost Escalation, Capacity, Phasing
(2008)Report 3: Financing Base, Organisational Design
(2010)Report 4: Stakeholder Support/Opposition,
Acceptability, Understanding (2011)
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Organising the funding of SHI
Households
SHI fund
Other taxes Income tax
Income tax rebate
GovernmentTaxes
Income taxrebate
Payrolldeductions