Wednesday, January 5, 2011

Getting Health Reform Right

Peter Berman, William Hsaio, Michael Reich, and Mark Roberts -- authors of Getting Health Care Right: A Guide to Improving Performance and Equity -- have consulted around the world helping countries design health policies and systems. (Hsaio was an instrumental figure in Taiwan's adaptation of National Health Insurance in 1995.) Over the years, the group has developed ten guiding principles for reformers:

  1. Clarify goals and values. A health care systems is a means to a number of ends, and it's vital to articulate precisely what those ends are. Moreover, they must be achievable in a context that is both politically feasible and ethically sound.
  2. Diagnose the root problem -- honestly. Work backwards from a problem until you've have identified its source, which might be anything from costs to corruption to apathy to ignorance of public health.
  3. Build health systems, not just medical systems. A effective health care infrastructure is horizontal, based on prevention driven by funded and staffed subsystems for primary care, sanitation, nutrition, and education.
  4. Plan based on your nation's history, culture, and needs. 
  5. Remember: Experts don't know everything: Reflect on personal values and political strategies, and incorporate them.
  6. Become a political animal. Reform is about more than policy. "Reformers need to embrace, not shun, politics."
  7. Just do it. Reform won't happen in one fell swoop, and there will be setbacks. Focus on progress and keep plugging away.
  8. Refine and refine. Fixing one thing might break another. Make refinements using the five "control knobs" of financing, payment, organization, regulation, and behavior.
  9. Learn from mistakes. Accept that health care reform means two steps forward and one step back. Learn not only from your steps back, but from the errors of others.
  10. Be proud of what you do. Rewards are few and far between, and the time required for meaningful change means that many reformers do not live to see the fruits of their labors. Look to yourself for validation and know that what you do is important.
For details, see PHC's Harvard Public Health Review article here.