1Prince Mahidol Award

Foundation under the Royal Patronage

@

Regulation in Health Service Delivery System

Viroj Tangcharoensathien, Supon Limwattananon, Walaiporn Patcharanarumol, Chitpranee Vasavid,Phusit Prakongsai, Suladda Pongutta

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Increasing the role of private sector in service provision,

•Cost-escalation, (overcharging, unnecessary high tech. equipment, etc)

•low standard of care, (medical malpractice, etc.)•low effective health regulation

• To understand the global issue of private healthcare sector, challenges & opportunities with respect to

health regulation• To better understand the government regulatory

capacity

Review both published & gray literaturesAn assessment of performance of health

regulation Self-administered questionnaire survey to 105 countries on

September 2008

Overview1. Regulatory measures 1.1 Direct command-and-control 1.2 Incentive-based measures 1.3 Self-regulation2. Government stewardship & governance3. The role of consumers4. Characteristics of survey response countries5. Survey results6. Conclusions7. Recommendations

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Figure 1 Five key regulators & their regulatory measures operated under three main constraints

Regulate private health sectors price,

quantity, quality, &

distribution &

information

Political, administrative, information constraints

Gov. agencies

Command & control,

registration, licensing,

inspection, sanction non-compliance

HA agencie

s

Accreditation, quality

improvement

certification

Professional councils

Qualification professions, control for

entry to market

NGO, consumer protection

agencies

Watch dog role,

media to ensure

consumer voice heard

Financing agencies

Competitive

contracting,

financial incentive

• LMIC the legislation on health facilities < health practitioners • Regulatory requirement in LMIC less demand than HIC• Low enforcement & its effectiveness (Asiimwe et al., 1993; Mujinja et al.,

1993; Yesudian 1994).

• Developing countries remains unimplemented, weakly implemented due to lack of regulatory capacity or being perverted by powerful vested interests( Bennett et al., 2005).

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1.1 Command-and-control measures

• Bureaucratic & very rigid regulatory control may unexpected results or failed.(Pakistan, China, India)

• Multi-faceted strategy; inspection, education, enforcement. (Lao, Thailand, Vietnam)

• To change the behaviour in delivering & utilizing HC services• Both financial & non-financial forms (Kumaranayake, 1997)

• Result-based financing and service contractingLMIC experiences suggest, contractual agreements on HC services

are more like a long-term relational contracting rather than a formally enforced, written contract as in the developed countries

• Doing the private business: LIC imposed the regulatory procedures on the business more than HIC

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1.2 Incentive-based measures

Number of procedures risks of corruption

The process-oriented regulation of service quality may include:•accreditation (re-accreditation) of health facilities, educations for health personnel, •certification (re-certification) of practice specialties.

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1.3 Self-regulation

• Accreditation is a voluntary process of institutional self-regulation, an explicit standards are required

• Self-serving in favor of the interests (USA)• Slow productivity in early phase due to lack of

incentive (Zambia)

• Inactive bodies (India, Thailand, Zimbabwe)

The GOV. has a fundamental responsibility to set the rules of engagement for all actors in public & private sectors in the systems.

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Stewardship(oversight)

Creating resources

(investment & training)

Financing (collecting, pooling &

purchasing)

Delivering services

(provision)

Functions the system performs

Responsiveness (to people’s non-medical

expectations)

Fair (financial) contribution

Health

Objectives of the system

Relationship between functions & objectives of a health system Source: Musgrove et al. (2000)

Measure of country’s governance, developed by WB since 1996

Six dimensions: (1) government effectiveness, (2) regulatory quality, (3) rule of law, (4) control of corruption, (5) voice &accountability, (6) political stability & absence of violence

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Worldwide Governance Indicators (WGI)

• Government effectiveness, regulatory quality, rule of law, have linearly positive link with economic status.

• Might be HIC is in a better position to invest in human resources and social capital

HTI

GEOVUT

MWI

MYS

IND

ISL

BWA

BDI

ECUAGO

MLI

PAN

GTM

BLZ

LBY

EGY

COG

BTN

ATG

IRN

KWT

KOR

MDA

FJI

BEL

UKR

FIN

BFA

KEN

MKD

SLB

ARM

LTU

JOR

ERI

LAO

ITA

VEN

VCT

GRC

TON

GHA

PRY

IRL

NIC

ETH

DMA

DOM

NLD

NPL

JPN

BLR

ALB

GBR

HRV

HND

CHE

TJK

SVN

AUS

YEM

GUY

TTO

BGD

THA

ZWE

PAK

MDV

UZBKHM

BHR

ROM

NZL

TZA

MUS

SWZ

TCD

LUX

CYPMLT

CZE

LSO

NOR

DEU

KAZRUS

CAF

DJINGA

GMBBOL

DZAIDN

LBN

AUT

DNK

PHL

PRT

KIR

SAU

ZAR

LKA

LCA

CIV

SVK

TUR

MOZ

CHN

BRN

GRD

ARG

GIN

MEX

MDG

TGO

LVA

JAM

GAB

CAN

NAM

NER

ZMBMRT AZEMNG

ISRCHL

BGR

POL

SWE

COM

GNB WBG

CMR BIHMHL

ZAF

CRI

SENPER

URY

PNG

BRA

UGA

MAR

BEN

GNQ

SYR

VNM

TUN

TMP

SGP

KNA

SLV

FRAEST

CPV

HUN

SDN

KGZ

ESP

OMN

SUR

LBRSLE

COL SYC

HKGUSA

FSM

SMR

RWA

STP

-2

-1.5

-1

-.5

0

.5

1

1.5

2

WG

I's G

over

nmen

t Eff

ectiv

enes

s

100 200 500 2000 5000 20000 50000

875

3465

1072

5

Gross National Income per capita (USD)

Governance vs. National income -2007

R2 = 0.69

• Country-level analyses revealed a significant link between the population health outcomes and the health expenditure a country spent (Filmer et al., 1999; Wagstaff, 2002; Bokhari et al., 2007).

• In developed countries, market mechanism places the high priority to civil society involvement, such as public information, and local initiatives to strengthen citizens’ voices.

• In developing countries, consumer information & disclosure as a regulatory intervention are less implemented than other measures.

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Consumers are important in bringing to light information on the functioning of the HC system

Educating consumers is a powerful way to make people well aware of their rights and what is the good health care.

•In Zimbabwe, campaigns against excessive injections and prescriptions have thought to be successful (WHO, 1991).

•In India, consumer groups taking the case to court (Mudur, 1995)

•In Nigeria, campaigns increase public awareness of the rights to quality health service. (Fatusi et al., 2006)

Region a

LIC MIC-L

Total number of countries

Respondents

(%)Total number of countries

Respondents

(%)

Eastern Asia & Pacific

10 6 (60%) 12 5 (42%)

Eastern Europe & Central Asia

8 0 12 4 (33%)

Middle East & North Africa

1 0 11 4 (36%)

South Asia 6 3 (50%) 2 1 (50%)Sub-Saharan Africa

39 8 (21%) 4 1 (25%)

All 64 17 (27%) 41 15 (37%)Table 1 Survey response rate by world region , a The World Bank’s classification of world regions

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• The sample countries are relatively poorer• the sample countries are better in term of governance performance than the

group average of WGI. • MIC-L, the difference is obvious, the samples are better performed in term of

regulatory quality, rule of law, government effectiveness & control of corruption.

• LIC, have better overall governance, despite poorer & lower health spending compared to the group average.

Three major regulatory constraints(1) Political constraints & regulatory capture (2) Administrative constraints:  (3) Informational constraints:  

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• LIC, high administrative constraint across five regulators.• MIC, pattern not clear

• The GOV. regulatory agency has relative higher levels of all three constraints than other key regulators.

•  NGO & CSO had the least though high level of political constraints especially in LIC group where 36% reported high level of constraints.

• Evidence from the self-assessment on different levels of three constraints prompts to policy interventions

• The administrative & information constraints are relatively easy to be implemented than political constraints.

• The institutional capacity to implement health regulation tends to be strongest for the rule setting > enforcement > monitoring.

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1. Private health sectors had a major role in terms of magnitude of service provision & household direct expenditure on their service.

2. LIC & MIC-L, government regulatory capacity are weak.

3. Administrative & information constraints seems to be more easy to solve than political constraints

4. LIC & MIC-L, three phases of regulations, rule setting, enforcing and monitoring compliances. Rule setting is strongest.

5. Challenging pre-requisite of increased gov. capacity to better regulate.

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1. Administrative & information constraints are not too difficult to solve. Targeting the professional councils, government regulation agencies who provide licensing professionals & registering medical premises.

2. Political constraint can be solved by • More developed Social Health insurance & pre-payment schemes•The better the capacity of gov. to steer private health sector

3. Good governance through the potential role of NGO & CSO as a watch dog (?)

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4. Beyond rule setting, strengthening capacity on enforcement & monitoring of compliance are needed.

5. Establishing or expanding financial schemes are needed for longer term. In the future, Health insurance system can play an increasing role through contracting & purchasing functions.

6. Accreditation & quality assurance mechanisms require more sophisticated health systems benchmarking and capacity on continued quality improvement.