Political Prestige or Consumer Focus?

Commentary, Healthcare & Welfare, Johan Hjertqvist

In Manitoba, as in most Canadian provinces, health care is a key subject for political debate. Unfortunately, the polemics of election campaigns tend to drive out hard analysis and facts. The current campaign in Manitoba seems to be no exception. The health needs of consumers are taking second place to the competition for political advantage.

Luckily for the many Manitobans who are showing dissatisfaction with the present system, a body of reliable experience around the world has demonstrated how better strategies can improve the efficiency of health care. In a world of open borders, there is less and less room for a narrow-minded parochialism that presents the Canadian – or Swedish, British or American – solutions as ultimately superior. The dramatic change of Swedish attitudes in recent years provides a good illustration.

For years, it was a given that the county council model would be in charge of Swedish health care. Reflecting a strongly socialized and integrated structure, these elected political bodies operated as a monopoly with regard to policy, funding, service provision and the assessment of outcomes. Such an environment neither provokes nor welcomes new ideas and behaviour. Locked into dogmatic and fixed solutions, such systems proved incapable of meeting the demands from health consumers, co-workers and taxpayers. It took a sharp economic crisis ten years ago to shake new life into Swedish thinking about health policy.

A growing number of countries drew the same conclusions, not the least throughout the European Union, which, like Manitoba, faces a demographic and labor force crisis. Governments of all colours came to understand that consumer power is changing the perception of health care and that new governance tools are necessary to make public health-care systems deliver the goods. A strong vision where public-private partnerships replace monopolies emerged.

What evidence shows the power of these kinds of partnerships?

Social Democratic governments in the United Kingdom and Germany are selling public hospitals to private – often for-profit – players. Why? These new owners have proven to be more efficient operators, delivering more and better services for every pound and euro spent.

In Germany, the government is desperately looking for ways to trim its expensive health-care system by the use of competition and benchmarking among providers. British Prime Minister Tony Blair recently announced a new goal: within three years, every English patient will have a free choice between a publicly owned and a privately owned hospital – both tax-funded.
The current National Health program for improved alternate access has increased surgical productivity by more than ten percent since it invited private providers to cut waiting lists. Blair is expanding it.

In Spain some regions have successfully invited contractors to run large hospitals, with the freedom to devise the best solutions in practice. In Norway, a new kind of federal HMO with professional management distanced from party politics took over emergency care two years ago. The delivery of all primary care has also been privatized. A recruitment crisis has been solved by a strong inflow of GPs, as post-reform Norwegian doctors have become self-employed and paid by fee-for-service.

In large parts of Sweden as well, reforms in hospital reimbursement during the 1990s built a system where compensation is related to outputs. This is the simple explanation – no secret in Sweden – for a strong and rapid growth in productivity in the early part of the decade, which cut waiting lists and freed up resources for an increased number of treatments. A high-jumping productivity improvement of close to 20 percent obviously improved access.

During the last year, Sweden’s Social Democrats have made a dramatic U-turn. They abandoned their policy of legally prohibiting the transfer of public emergency hospitals to private owners and now are suggesting quite the opposite. Soon, for-profit providers may have the opportunity to own and/or operate between 50 and 60 Swedish emergency hospitals.

Why? Private institutions have proven to be more efficient, handling staff in more creative ways and easily adapting organizations and routines to meet new conditions. In the Stockholm region, the new center-left majority has continued the competition-based health policy, using private entrepreneurs and incorporated public hospitals.

In countries like Denmark, Belgium and France – where the populations in every evaluation show high satisfaction with health-care realities – living public-private partnerships offer the consumer a mix of publicly owned, privately owned, publicly funded and privately funded health services. Every citizen is guaranteed good treatment and freedom of choice. The access is very good, still far better than in metropolitan Stockholm, which reports the best figures in Sweden.

Successful health systems in Europe are pragmatic. They use their full energy to deliver consumer-related services rather than to keep national illusions and dogmas alive. In these countries, high quality, accessible health care is a natural part of the culture rather than a function of political self-image. International ranking agencies today seriously challenge the official view of the Canadian system as a rare jewel. Rare perhaps, but with a fading lustre.

In many parts of Canada, I have encountered not only interesting ideas for health-care improvement, but also new strategies. Waiting list information on the Internet is one such step. Why not look into these approaches with open minds? Health consumers and providers are asking for change, and new solutions. It is a matter of legitimacy for the Canadian health system.

Inspiration and good examples from other places are plentiful. Manitoba should welcome the world of health-care reform, not use the occasion of an election campaign to demagogue away the chance for positive change.