Understanding Hospitals in Changing Health Systems

Antonio Durán, Stephen Wright, Antonio Durán, Stephen Wright

• Publisher: Palgrave Macmillan
• Year: 2019
• ISBN:
  9783030281724
• Topic: Politica e relazioni internazionali
• Subtopic: Politica pubblica

"This timely book provides insight into the changing role of the 'hospital' in the face of technological, organizational innovation and ever-tightening health budgets." James Barlow, Imperial College Business School, UK
"This book covers various relevant aspects of the hospital in different states and contexts. Underlining the importance of business models for future hospitals, this publication presents models of care from a historic and a current perspective. All authors possess a deep insight into different health care systems, not only as scholars but as experts working for world-renowned health policy institutions such as the World Health Organization, the World Bank or the European Observatory for Health Systems." Siegfried Walch, Management Center Innsbruck, Austria
"For an organisation like mine, representing those involved in the strategic planning of healthcare infrastructure, this book provides invaluable insights into what really matters – now and for the future – in the complex and contentious field of hospital development." Jonathan Erskine, European Health Property Network, Netherlands
This book seeks to reframe current policy discussions on hospitals. Healthcare services turn expensive economic resources—people, capital, pharmaceuticals, energy, materials—into care and cure. Hospitals concentrate the use and the cost of these resources, particularly highly-trained people, expensive capital, and embedded technologies. But other areas of health, such as public health and primary care, seem to attract more attention and affection, at least within the health policy community. How to make sense of this paradox? Hospitals choose, or are assigned, to deliver certain parts of care packages. They are organised to do this via "business models". These necessarily incorporate models of care – the processes of dealing with patients. The activity needs to be governed, in the widest senses. Rational decisions need to be taken about both the care and the resources to be used. This book pulls these elements together, to stimulate a debate.

© The Author(s) 2020

A. Durán, S. Wright (eds.)Understanding Hospitals in Changing Health Systemshttps://doi.org/10.1007/978-3-030-28172-4_1

Begin Abstract

1. Introduction: Why This Book?

Antonio Durán¹ , Stephen Wright² , Paolo Belli³ , Tata Chanturidze⁴ , Patrick Jeurissen^{5, 6} and Richard B. Saltman⁷

(1)

ALLDMHEALTH, Seville, Spain

(2)

Independent Consultant, Ingleton, UK

(3)

The World Bank, Nairobi, Kenya

(4)

Oxford Policy Management, Oxford, UK

(5)

Radboud University Medical School, Nijmegen, Netherlands

(6)

Ministry of Health, Welfare and Sports, Hague, Netherlands

(7)

Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA

Antonio Durán (Corresponding author)

Email: [email protected]

Stephen Wright

Email: [email protected]

Paolo Belli

Email: [email protected]

Tata Chanturidze

Email: [email protected]

Patrick Jeurissen

Email: [email protected]

Richard B. Saltman

Email: [email protected]

Keywords

AttributesBusiness modelsCare servicesCurative servicesDecision analysisDeterminants of health statusFunctionsGovernanceHospitalsHuman capitalModels of careOwnershipPayment mechanismsPhysical capitalPublic healthResourcesTechnology

End Abstract

Introduction: Hospitals in Health Systems

The authors of this book include health policy, management and finance professionals—mostly European but with different backgrounds and affiliations—across government, academia, international institutions and consultancy. We have been concerned for some time about the presentation of hospitals in public health policy discourse and analysis, and found colleagues sharing our concern and emphasizing the importance of the issue. This chapter represents the group consensus on the main content and on the direction of our effort in the book. We feel that global health dialogue has “moved away” from hospitals in recent times in an inappropriate way—yet in most countries hospitals do play today and in the future will continue to play an absolutely critical role (and for good reasons that will be explained in the book!). The point is not to defend the position of hospitals; it is to understand them and therefore be in a position to make judgements about what hospitals should and should not do—within their contexts.

Rather than seeing hospitals always and exclusively as a “problem” (“too costly”, “too powerful”, etc.), one of the critical issues for this book is that hospitals across low-, middle- and high-income countries can become a true source of hope for people who currently do not have adequate access to quality services. In order to contribute to make hospitals play such a vital role and develop their future potential, we address the need to better understand the function that hospitals have now and should have in the health systems of the future, what their core institutional dynamics are, and how they should be governed, structured, owned, paid and so on. We intend these messages principally for the international health policy community and for those involved as decision-makers in health, healthcare and hospital systems.

At first, we wanted merely to warn about the risks of neglecting or misunderstanding hospitals in the global health picture in the face of what we understood as an undeniable evidence (hence the metaphor between us of an “elephant in the room”). It was only when we found resistance even to discussing the core issues that we realized the need to expand and deepen our analysis in the form of this book. A shift in the paradigm of healthcare provision—and within it, of the hospital—based on better understanding of its foundations is required.

Stating the point in these terms immediately raises a first issue regarding the meaning attached to the label of “hospital”: is it the same everywhere? Clearly not, and for obvious reasons. The name “hospital” has a known diversity of meanings, affecting aspects such as:

• different things in different places (Western Europe, post-Communist Europe, North America, emerging economies);
• different sizes, functions, shapes, ownerships and so on; and
• different content in different times: past and present.

The main themes which have so far emerged from the discussions go well beyond Europe, into low- and middle-income countries (LMIC)/ and ex-Communist, North American and Asian/Japanese circumstances. In other words, we recognize that there is of course a path dependency in how health systems have developed, but we look for the things that generally distinguish hospitals from other parts of those systems—which are receiving comparatively much more attention.

However, we argue in this volume that there can be significant commonality in the core understanding of the label; and we define it below in ways that we hope will allow the facilities and institutions to be recognized and analysed even if their settings are very different. In Europe alone, the European Observatory on Health Systems and Policies has published in recent years at least four books on hospitals (McKee and Healy 2002; Rechel et al. 2009a, 2009b; Saltman et al. 2011); the intention here is to build on this and related work, but move further in terms both of analysis and of policy significance for confronting the challenges ahead.

Hospitals are conceived in this book as inseparable constituent parts of health systems (Murray and Frenk 2000). Every health system as defined by the World Health Report 2000 (WHO 2000) is supposed to pursue a series of goals, the most important ones being health-related (level and equity of health); protecting citizens from the catastrophic financial consequences of fighting disease (i.e. providing “coverage”); and responding efficiently to citizens’ expectations/client orientation in the non-medical sphere; this latter goal can be taken to include the provision of information to patients/clients as important collateral. The core end-objective or key outcome target of any health system should be the maintenance, or preferably the increase, of health status (measured at collective and individual levels) in the maximum number of the target population.

The achievement of the above listed objectives of any health system, in this classic World Health Report 2000 view, depends on four central functions (“sets of repeated activities and tasks needed to achieve certain distinctive goals and objectives”), namely: (1) service production, (2) finance, (3) regulation/stewardship and (4) inputs creation/development. The graph below addresses such relationship (Fig. 1.1).

Fig. 1.1

Relations between functions and objectives of a health system (WHO—World Health Organization [2000] World Health Report 2000. Health System Improving Performance [Geneva: World Health Organization] 2:25)

In this view of health systems, hospitals are a critical part of service delivery, and essential loci to assemble together specific resources to make modern healthcare possible; they require inputs to be assembled, and they need governance and finance to be made available. The current emphasis on universal coverage is perhaps the most visible application of those ideas and principles (WHO 2011).

There is a genuine and politically crucial concern with respect to the importance of hospitals, often the body of almost ethical confrontations, with some in the health policy community defending a position which essentially challenges their very existence (as though “public health and primary care are all that matter”). Decades of pioneer research have showed that in developed countries, advances in health indicators were historically related to improvements in food, education, housing and so on (Dubos 1959; McKeown 1965). Relatively similar results were obtained when an analysis in developing countries followed suit (Preston 1980). These findings shifted policy attention towards primary healthcare, from around the time of the Alma Ata Conference in the late 1970s, a line of argumentation vigorously supported by the policy community ever since (Evans et al. 1994).

Importantly, while the above-mentioned pioneer studies reflected the impact of all healthcare on health outcomes improvement to be around some 20% at its most (with all the rest contributed by environmental and behavioural “social determinants of health”), recent research in OECD countries has put the figure attributable to healthcare higher, at between 44% and 57% (Arah et al. 2006). In Europe, studies like this on “health-care-amenable mortality” by the London School of Hygiene and Tropical Medicine estimate the influence of medical care on health indicators improvement to be not far from half (Nolte and McKee 2008; Figueras et al. 2008); that is, this proportion of deaths has been avoided in each given country in recent years because the healthcare systems were performing well.

These are estimates of “mortality”, tightly defined for the purposes of analysis by demographic cohort and disease type. Surprisingly, no comparable work has been carried out on sickness, as distinct from death—“morbidity”—though a first expectation would be of a comparable impact on it from healthcare. Further, a substantial part of progress in both avoidable mortality and avoidable morbidity will undoubtedly be due to hospitals. It is, however, a rather surprising issue that the topic has scarcely been studied, which explains that not even approximate figures are available. Such a research void needs to be filled as urgently as possible.

Confusion About What a Hospital Is

One major problem is that definitions of a hospital are invariably superficial. For example:

• Oxford English Dictionary (n.d.): “An institution providing medical and surgical treatment and nursing care for sick or injured people” (… but there are many institutions which do that but which are not hospitals);
• WHO (www.​searo/​who/​int/​topics/​hospitals/​en, accessed 17/11/2017): “Health care institutions that have an organized medical and other professional staff, and inpatient facilities, and deliver services 24 hours per day, 7 days per week” (… but not all hospitals have inpatient facilities, as emergency care hospitals and selected facilities show, or work continuously on 24 × 7 base...

Table of contents

• Cover
• Front Matter
• 1. Introduction: Why This Book?
• 2. Hospital Governance
• 3. Models of Care and Hospitals
• 4. Business Models and Hospitals
• 5. Hospital Care: Private Assets for-a-Profit?
• 6. Hospital Payment Systems
• 7. Hospitals in Different Environments: A Messy Reality
• 8. Why Is Reform of Hospitals So Difficult?
• 9. Decision Analysis
• 10. Conclusions
• Back Matter