Transcript (보건학개론_2012)_권순만교수님x

보건정치경제
(Political Economy of Health
Systems and Policies)
March 2012
Prof. Soonman Kwon, Ph.D.
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Soonman KWON
Ph.D. (Health Economics and Policy),
Wharton School, University of Pennsylvania, 1993

Academic Appointments
School of Public Policy, Univ. of Southern California, 1993-96
School of Public Health, Seoul National Univ., 1997-present

Visiting Professor
Germany: Univ. of Duisburg, Dept of Economics (summer 1999),
Trier (summer 2001, DAAD scholar), Bremen (summer 2003)
Harvard School of Public Health, Dept of International Health (Takemi Fellow
and Fulbright Scholar: January-August 2002)
London School of Economics and Political Science, Dept of Social Policy (Sep
2002 - Jan 2003)
Hosei University, Institute of Aging, Japan (January 2004)
University of Toronto, Dept of Political Science (Jan-Aug 2006)
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Teaching
- 보건정치경제 (Political Economy of Health Systems and Policies)
- 보건재정정책 및 관리 (Health Care Financial Policy and Management)
- 비교보건정책 (Comparative Health System and Policy)
- 노령화와 장기요양정책 (Aging and Long-term Care Policy)
보건정치경제 연구실: www.heamang.net
국내 학회 활동
- 한국노년학회 부회장 역임
- 한국보건경제학회 부회장 (현재)
- 현재 보건행정학회 학술이사, 사회보장학회 기획이사
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최근 연구 용역 (연구책임자)
- BK (Brain Korea) 노인보건정책연구팀 연구책임자
- Impact of economic recession on health in Asia (ADB/WHO)
- Framework for assessing health system in developing countries (GTZ)
건강보험 보장성 강화 전략 (보건복지부)
건강보험 보장성 우선순위 원칙 및 적용방안 (건강보험공단)
암보장성 강화정책의 효과 평가 (NECA)
한국 의료보장 선진화 방안 (기획재정부)
장기요양 급여비용 결정구조 개선 방안 (건강보험공단)
지속가능한 장기요양보험 재정추계 (보건복지부)
장기요양보험 도입의 경제성 평가 (보건복지부)
국내외 제네릭 약가 비교 (보건복지부)
DUR 시범사업평가 (건강보험심사평가원)
보건의료 국제개발사업 수행체계 및 프로그램 개발 (보건복지부)
남북 보건의료협력사업 경제성 평가 (보건복지부)
공공의료기관 경영효율화 방안 (국가경쟁력강화위원회)
건강형평성 성과 지표 개발 (보건복지부)
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국제학술지 편집위원 (Editorial Board Members)
Social Science and Medicine
Health Economics Policy and Law
Health Systems in Transition (HiT)
BMC Health Services Research
Ageing Research Review
국제기구 위원회 위원 (Committee Members):
- WHO Alliance for Health Policy and Systems
- GAVI (Global Alliance for Vaccines and Immunization)
국제기구 Consultant
Bhutan (WHO), Cambodia (WHO, GTZ), China (ADB, WHO), Cuba
(WHO), Fiji (WHO), Indonesia (WHO), Iran (WHO), Kenya (GIZ),
Lao PDR (WHO, World Bank), Malaysia (WHO), Maldives (WHO),
Mongolia (WHO, ADB, World Bank), Myanmar (WHO), Pakistan
(GTZ), Philippines (GTZ, EU), Uganda (GTZ), Vietnam (WHO, World
Bank)
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I. Health, Health Policy, and Health
System
Health: Health is a state of complete physical, mental and
social well-being and not merely the absence of disease
or infirmity (WHO)
-> basic need of human being
- > Necessary to fulfill other (political, economic) needs
Public Policy (Klein and Marmor, 2006)
What governments do and neglect (or decide not) to do
About politics, resolving conflicts about resources,
rights and morals
-
Authoritative allocation of values within society
(efficiency vs. equity; government vs. market;
individual vs. social responsibility)
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Perspectives on Policy (or policy-making)
- Puzzling about ways of tacking social problems: rational
policy analysis, finding out the optimal solution,
economic evaluation
- Bargaining between different interests: process,
incremental and evolutionary
(Definition, interpretation and framing of problem is
political: e.g., financial sustainability of health insurance)
Contexts (or determinants) of Public Policy
Idea: value, ideology, interpretation, legitimization
Interest: distributional consequences, medical profession
Institutions: machinery, formal and informal rule of the
game, political institutions
History: path dependency, legacy, past experience
Comparative, policy learning
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Health Care System: Resources and Organizations
(Input, Throughput and Output)
1) Health care financing: different types of financial
resource mobilization
- public (tax, social insurance) vs. private (private
insurance, out-of-pocket payment)
- coverage, benefits, resource allocation, payment to
providers
- health expenditure
2) Health care delivery: health manpower and facilities,
pharmaceuticals and technology
3) Health outcomes: health care utilization,
life expectancy, mortality, morbidity
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Example: World Health Report 2000
Health Systems: Improving Performance
- Level (achievement) of health outcomes
- Distribution of health outcome (horizontal equity or
equality)
- Responsiveness of health systems
- Distribution of responsiveness
- Fairness of financial contribution (vertical equity)
 Level vs. distribution (efficiency vs. equity)
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Percentage of GDP
Health Expenditure as a % of GDP
8
7
6
5
4
3
2
1
0
Government health spending
Private health spending
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Source: WHO, Health Financing Strategy in Asia and the Pacific (2010-2015), 2009
life expectancy at birth
60
70
80
90
Relationship between Health Expenditure
and Health Outcomes
Singapore
Japan
Australia
New Zealand
Republic of Korea
Brunei Darussalam
Cook Islands
China
Maldives
Thailand
Malaysia
Viet Nam
Jordan Palau
Philippines Fiji
Tonga
Vanuatu
Sri Lanka
Samoa
Mongolia
Indonesia
Bangladesh
India
Tuvalu
Bhutan
Nepal
Cambodia
Papua New Guinea
Lao People's Democratic Republic
Niue
Micronesia
Kiribati
Timor-Leste
Nauru
Marshall Islands
50
Myanmar
0
5
10
Health E as % of GDP
Source: WHO, World Health Statistics 2010
15
20
11
90
Japan
80
Singapore
Australia
New Zealand
Republic of Korea
Brunei Darussa
China
Cook Islands
Malaysia
Viet Nam
Sri Lanka
Thailand
Tonga
Fiji Vanuatu
Indonesia
Samoa
Solomon island
North Korea
Bangladesh
India
Mongolia
Bhutan
Nepal
Papua New Guin
Lao People's D
Cambodia
Maldives
60
70
Philippines
50
Myanmar
2
Data: WHO, WORLD HEALTH
STATISTICS 2009
4
6
health E as % of GDP
8
10
12
% Public in Total Health Expenditure
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Source: OECD Health Data 2011
H Expenditure and Life Expectancy (2008)
Source: OECD Health Data 2011
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II. Types of Government Intervention
and Policy in Health Care
1.
Different Mechanisms
a. Mandate: final incidence?
On the employer: labor market
On the consumer: product market
b. Financial incentive: depending on the market mechanism
Voucher, conditional cash transfer
Tax exempt for the premiums for private health
insurance
c. Direct provision: NHS (National Health Service), public
hospitals
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2. Different Types
1)
Entry regulation: license (for minimum standards),
certificate, allowing new providers or beds according to
government planning or need assessment (e.g., CON
(Certificate of Need) in the US)
-> could be anti-competitive
2) Price regulation: price regulation of medical care (fee
scheduling), price regulation of pharmaceuticals and
device
3)
Quality
regulation:
safety
and
efficacy
of
drugs/technology, accreditation of providers, medical
malpractice (negligence vs. strict liability rule)
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2. Different types (continued)
4) Provision of information (to mitigate the problems caused
by
information
asymmetry):
Evaluation
and
dissemination of the information on quality
a. Evaluation of health care institutions:
input – throughput – output ?
b. Evaluation of services: e.g., C-section rate, antibiotics use
-> how to adjust for patient severity?
c. Practice guidelines for providers
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3. Different sub-sectors
a. Physicians: regulation on advertising
- informative or deceptive (wasteful competition)?
- depends on search, experience, and credence good
(characteristic)
b. Hospital: requirement on personnel and facility for quality
c. Payer: Mandate for the payer to accept all applicants (no
cream skimming), mandate community rating or incomebased contribution, uniform or minimum benefit package,
d.
Pharmaceuticals: reference pricing, advertising on
prescription drugs, requirement of substitution of generic
for brand-name drugs, technology assessment, listing
(positive or negative) for reimbursement
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III. Determinants and Process of
Health Policy
Public Policy
Institutions, Idea, Interest, History
1. Institutions (제도): Formal and informal rule of game
-> Rule of articulating and responding to preferences and
social demands (Immergut, 1992)
Political Institutions: Constitutional arrangements,
organizational structures, conventions of policymaking
(Tuohy, 1999) -> affects the course of policy making
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2. Idea or Value system
Value, Idea, Moral, Norm: Assumptive world,
interpretation of real world
- How health is defined
- Who is responsible for health?: individual vs. social
- Trust on the government (public sector)
Three types
- Communitarian: family or social groups
-> Germany, Netherlands, Japan
- Egalitarian: entitlement or right to health
-> Sweden, UK, New Zealand
- Individualistic: USA, Australia
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3. Interest Group Politics in Health Care
Separation of Drug Prescribing and Dispensing
OTC drug sales in supermarkets
Physician opposition to payment system reform
Physician, professional dominance
Information and knowledge
Financial resources
Cultural hegemony
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4. Role of History: Institutional Stickiness, Path
dependency or Policy legacies
- Future options are foreclosed by past decisions (Klein, 2006)
Extent to which particular mode of policy action become
institutionalized in a given policy area (Tuohy, 1999)
e.g., Similarity between public financing (tax or social
insurance) for health care and long-term care
- tax financing in Scandinavian countries
- social insurance in Germany, Japan, and Korea
e.g., Informal rules and culture are difficult to change (e.g.,
attitude toward drugs in Asia)
e.g., Political culture, conservatism in Japan
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