Health-care systems are large and complex systems that undergo changes constantly. In order to steer them in the set direction, health sector reforms are under consideration in countries throughout the world, no matter their level of income.
A reform implies sustained, purposeful, and fundamental changes. While it is difficult to define precisely what constitutes a true health care reform, there is a widespread consensus that a reform is a process of change involving the what, who, and how of health sector action. Health sector reform should be based on a holistic view of the health sector.
Health system reforms can be divided into partial and global reforms. Partial reforms (day-to-day operational changes, developmental incremental issues) are aimed to only change one aspect of the system, so as to address a specific concern in a developing society (e.g. ageing). Global structural reforms, on the other hand, try to reshape the whole health care system. The sum of partial reforms in several elements of the system can lead to a global, comprehensive reform. Global reforms are designed and implemented when a set of major changes have occurred in the society (adding up demographic, political, ideological, social, economic, technological, cultural changes). Throughout the history, the USA have implemented global reforms of their health system each 25 or 50 years.
A considerable debate has been ongoing about the efficiency of a swift and radical reform compared to more incremental approaches. The ability to introduce rapid reforms depends mainly on the configuration of the governance structure and on political will, but it is also influenced by contextual circumstances, such as the state of the economy or the degree of support from key stakeholders. Radical changes based on ideology may not be politically and technically sustainable in the long term. An incremental approach may lead to more socially sustainable policies in the long term, especially in less stable political and economic environments (1). The best approach depends on country specific circumstances, but flexibility is recommended to be built into the implementation process; e.g. a combination of “big-bang” approach to pass the legislation and steady implementation within health sector institutions. Provider interests tend to be very well organised and generally command greater public trust than politicians. They therefore have enormous power over the reform process. It has been shown that when acknowledged leaders accept changes, others follow. The success of the implementation will depend on identifying strategies that help to change behaviour and inventing incentives for change.
The prerequisite for a successful health care system reform is knowledge of the key personnel included in the reform process, as well as detailed analyses focused on historical changes of the system. The preparation phase can build up experience and knowledge about the roles and positions of various stakeholders, which is important for the reform leaders. The evidence suggests that cross-national studies and international policy dialogue can speed up the process of “policy learning”, enabling governments to learn from one another, and thus avoid repeating others’ errors, although some degree of adaptation is usually required. While all countries have encountered the same basic challenges, they have manifested themselves differently because of differences in institutional and historical contexts (2).
The evidence suggests that an electoral mandate appears to be the most important in respect to reforms. It is not enough to win an election or command a parliamentary majority: it also matters a great deal if the government has made the case for reform to the voters before the election. Governmental mandate is not infinitely long. The skeleton of the reform should be launched in the starting days, the goals and content of the health care reform should represent the basis of the pre-election period. The mandate periods themselves are simply too short to be spent on situation analyses and goal setting (2).
Political will is a significant factor affecting policy implementation, and firm governmental commitment to changes is the essential aspect of success. The main goals should be necessarily inserted into the governmental political agenda, agreed and fully supported by the Ministry of Finance. An important constraint of health system reforms has been the position of health ministries, being accorded a comparatively low position in the political hierarchy. Besides, ministries of health are weak in comparison to social security or health insurance agencies (3).
A strong leadership of individual policy makers and institutions charged with carrying out reforms is essential. Lack of political leadership and unclear or vague general ideas of objectives can create a political vacuum, in which a variety of agencies, organisations and groups will seek to push their own reform agendas that are, to a larger extent, aligned with their own goals. Multiplicity of approaches and agendas to policy formulation can lead to inaction due to enhanced strength of partial interests of particular groups of stakeholders, such as insurance companies or groups of patients or providers (3).
Clear communication of long-term objectives of a reform is particularly important in a crisis: where reforms are undertaken in response to exogenous shocks, there is often a lack of clarity about their aims. An evidencebased and analytically sound case for reform serves both to improve the quality of policy and to enhance prospects for reform adoption (2).
The inclusive and collaborative approach to the reform is recommended from the beginning. The bottom up approach with building up achievements regularly with a clear mind set on predefined goals is the best way to proceed. It is important to engage those who will be most directly affected by the reform. Inclusive, consultative policy processes are no guarantee against conflict, but they seem to pay dividends over time, not least by allowing greater trust among the parties involved. The key to successful implementation is maximizing the potential of the so-called “policy friend” by establishing the alliance of supporters, individuals, organisations, agencies to oppose the influence of the opposition.
In all studies, the key question emerges of whether, when and how to compensate those who will lose out as a result of a reform. Concessions to potential losers need not compromise the essentials of the reform: it is often possible to improve the prospects of particular groups that will be affected by a reform without contradicting its overall aims. The failure to compensate may reinforce opposition to the reform, but excessive compensation may be costly or may simply blunt the effects of the reform. The most common compensation strategies involve “grandfathering” rents and long transition periods. Concessions in the form of “side payments”, such as policies in other domains that might offset the cost of reform for some groups, are employed less frequently (2). The general population is a particular set of stakeholders that can influence change. Persuading the general citizens of the need for reform can have an important enabling effect. This is especially true when the reform being implemented leads to a growing conflict between social and market values. Broad public support for reform can be an effective catalyst for change, just as lack of it can be a major barrier (4). The media can often be effective in promoting reforms and in seeking public support (5).
There is little agreement about what constitutes “best practice” for a successful reform. This is partly due to the complex mix of goals to be pursued, but it also reflects the lack of reliable, generally accepted indicators of the quality of outcomes and their value. Evidence-based reform is difficult where the evidence is either lacking or contested. That is why work by national or international organisations to generate reliable, credible evidence on policy outcomes can be very valuable in clarifying the terms of debate.
A good information system and technical skills, together with managerial skills, PR and media role have been shown as an important guarantee for the progress in health system reforms. Health care reforms, in particular, tend to be expensive - even if cost containment is expected in the long term, it often involves expensive concessions in the short term. Policy-makers should be prepared to invest additional resources to achieve particular objectives. More and better data and analysis, including international comparisons, often help, although a great deal depends on consensus regarding the value and meaning of such evidence.
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