19 May 1994 - 21 May 1994

The Shaping of Healthcare Systems

Chair: Sir Donald Maitland GCMG OBE

Our conference was the second of a pair, mounted in collaboration with the United Kingdom Health Education Authority and the University of Bath, to consider how to promote international learning about the design of national health-care systems. With the generous help of Smiths Industries plc we had participants from twelve countries, including five ex-Communist ones from Central and Eastern Europe. Many of our participants had contributed to a set of special preparatory papers.

We recalled that the shaping of health-care was a matter of vigorous debate almost everywhere, as popular interest in these matters of special personal immediacy encountered the fact - in some countries now politically acknowledged in a high-profile way for almost the first time - that provision (especially public provision) to meet every understandable demand was an impossible goal. The factors confronting all countries, albeit in varying degree, included the fast-widening possibilities created by technical advance; the near-inexorable rise, alongside these, of costs; the demands posed by an increasing proportion of the elderly among populations; the practical difficulty of dependably reaching all the more disadvantaged or alienated segments of society; and the complexity of choice, amid resource constraints, between remedial health-care and preventive health-promotion, and between patterns of care centred upon general practitioners and the contribution of specialists.

System inertia, we knew, was a serious problem in reform save perhaps in special situations (as after the collapse of Communism) where change might sometimes be arbitrarily demanded for its own sake. The instincts of most professional groups ran counter to change; the beneficial results of reform typically emerged more slowly than the discomforts; and public concern was easily aroused against any modification which seemed to threaten the removal of any existing feature of provision, however poor its coolly-assessed performance. The media could, given opportunity and will, play a valuable part in explaining the imperatives of change and choice, and the directions these might constructively take; but it was not always easy for them to command professional knowledge, especially in an international perspective. In practice, within most of our countries, they did not readily resist the temptations of the indignant headline on the individual hard case.

Immobilism - or conservatism channelling its campaigning energies simply towards constant demand for more resources to pour into the support of existing structures - was further reinforced by the fact that true receptivity to the implementation of reform demanded a complex conjuncture of circumstances, including for example an unusual public sense that change had to be accepted, government ability and readiness to expend political capital, and the availability of persuasive ideas about the particular character of reform. These last on their own could not generate the necessary tide; and they were moreover often hampered, or their scope narrowed, by a sense that health-care was an essentially domestic subject on which the concepts and experience of others bore little.

And yet reform - sometimes dramatic reform - was possible. We heard, not without surprise, of a programme in Saskatchewan that had closed 50 out of 137 hospitals without public uproar, and of abrupt and radical reorientation of almost the entire system in the Czech Republic. Given the possibility - and indeed the ultimate imperative - of change, what could be done to enhance the prospect that its design and implementation could benefit from sharing in the knowledge and experience of other countries?

We acknowledged that the wise transference of ideas and understanding was not a simple matter. In some of the ex-Communist countries, we were told, there was a grave deficiency of the policy-planning skills and attitudes needed for any well-judged exploitation of new ideas. More generally, in all countries careful study and sophisticated understanding were needed if beneficial middle courses for exploiting international learning were to be found between the sterility of using other-country examples simply as prejudice-supporting ammunition in domestic debates and the over-enthusiasm of attempting direct transplant without adequate reference to differences of context. Adaptive importation needed to consider prudently whether the key problems which a particular system had been designed to address truly coincided with the importer’s own; whether it fitted the underlying value-patterns of the importer’s society; and whether the implementing instruments presupposed by a particular design were, or could realistically be put, in place. Just for example, a taxation-based system, whatever its merits in its original context, could not sensibly be transported to a culture like that of the United States with its distinctive approaches to individual freedom and responsibility, or to an environment where tax-collection arrangements did not enjoy a reasonable level of public respect and observance.

As all this illustrated, the task of international exchange and learning on system design was a less clear-cut and straightforward matter than on more obviously “objective” matters like technical medical care. We did not however wish to conclude that this added complexity and difficulty pointed towards abandoning the effort - on the contrary, it might as probably point to a stronger need.

Useful exchange needed to rest on a clear grasp of what was the meaning of terms used - there were often widely divergent conceptions of what simple-looking and familiar words like “access” meant, and some sort of glossary might be very valuable if only to give warning of where mismatch could arise. Further dimensions of information transfer about system experience might include, in addition to basic system description, the identification of problems addressed (excess capacity in some sectors? inadequate coverage? poor responsiveness or accountability? misallocated or inadequate resourcing? inefficiency?) and of the critical participants in decision-making (the professions? media? politicians? public opinion?); the nature of the processes of design and decision, including the structure of consultation; the factors which generated receptivity to system change; the basic political or social attitudes which constrained the choice of options; and the methods and criteria which would guide the evaluation of outcomes (an aspect which, we noted, was customarily overlooked or underrated).

There were, we observed, various helpful mechanisms of international learning which had already been used, albeit mostly on a modest scale. These included exchange visits (by individuals or groups), cross-secondments, attachments, joint ventures and reciprocal consultancies. All these posed demands upon the time of people who were typically very busy already; but they offered the special advantage of first-hand observation. The choice whether to use such devices, and on what scale, must be for nations themselves, and not for any international body, to make; but international information resources could supplement or strengthen the learning process as a whole.

We were aware of international data-banks on measurable healthcare features like expenditure, and on health-outcome statistics; the OECD store was particularly mentioned, as was the possibility of more coordinated European Union data-gathering (provided this could be organised without provoking political fears of a new field of EU claim to executive competence). The OECD material however was of limited scope - it did not extend, for example, to the Central and East European countries. Many participants perceived a strong case for a new drive - in which the World Bank might perhaps be able to play a catalytic part - to broaden and systematise the accessible store of factual data of this kind.

In addition to such a drive, however, there was much support in discussion for a further resource of a rather different kind - for a clearing-house, in effect, of information about health-care systems, covering characteristics of the wider sort upon which our general debate had focused. Such data would inevitably, we recognised, be more judgmental, more highly-charged politically and less neutral than those of the other category. Partly for that reason and partly for informality and speed we were disposed to see advantage, were such a clearing-house to be established, in its being of a private rather than a governmental character, as well as of modest size - the role should be that of providing access and networking rather than undertaking its own study and evaluation. It was beyond the powers of the conference to direct action on this idea; but many participants clearly hoped that it could in some way be taken up.

This Note reflects the Director's personal impressions of the conference. No participant is in any way committed to its content or expression.

Chairman: Sir Donald Maitland GCMG OBE


Ms Lia Dover
Professor Richard Feachem
Mrs Zuzana Z Feachem
Dr Spencer Hagard
Professor Rudolf Klein
Dr Robert Maxwell CBE IP
Mr John O’Sullivan

Mr Michael B Decter
Dr Charles Hollenberg

Professor Martin Bojar

Dr Manfred Zipperer

Dr Tamás Angelus
Dr Peter Makara
Dr Eva Orosz

Professor Tadashi Yamada
Professor Tetsuji Yamada

Mrs Kieke Okma
Dr Jan Stiphout

Dr Janusz Halik
Dr Cezary Wlodarczyk

Dr Daniela Vâlceanu

Mr Peter Krnác CSe

Professor Per Carlsson

Dr Roz Lasker
Professor Theodore R Marmor
Professor James Morone
Dr Brant S Mittler
Dr Paige R Sipes-Metzler
Ms Linda J Schofield
Professor Deborah Stone

Dr Alex Preker