In my first policy blog, I shared three predictions about the future of health care based on health policies proposed or enacted around the world since 2020. This time, I turn to the broader-scale reforms governments have introduced or implemented around one of the hottest topics in health care: the pursuit of health equity.
Globally, no jurisdiction has completely rectified the systemic failures that have created and perpetuated racial and socioeconomic inequalities in health care. But this isn't to say they aren't trying to make improvements.
Governments are actively implementing policy solutions that range in scale—from overhauling entire systems to improving services for specific patient groups. In our global policy scan, we identified three archetypes of reforms that aim to improve health disparities.
The examples below illustrate the different angles through which governments are restructuring their health systems to improve access, quality, and outcomes for historically disadvantaged or marginalized patient groups—and the context in which these reforms are happening.
Of course, most health care leaders cannot devote the political capital to completely re-structure their health care system. But they can look to these examples for elements that may be replicable in their own context.
1. Centralizing and standardizing care coordination at the national level
Where it's happening: New Zealand
Why: In 2018, the federal government commissioned a review of the health and disability system that revealed regional disparities in care quality and racial disparities in outcomes.
How: In April 2021, New Zealand began a complete restructuring of their health system. The federal government centralized the roles of 20 regional organizations (called District Health Boards or DHBs) into a single entity, Health New Zealand. Health New Zealand now coordinates and commissions all health services—including hospital, specialist, primary, and community care—at the national level. By centralizing care planning, coordination, and commission at the national level, the government aims to improve visibility into resource availability across the system and to redistribute resources more equitably—thereby ending the "post code lottery" system under which the quality of care a patient receives varies by location. The reform also created the Māori Health Authority--a national, dedicated institution focused on improving care quality and outcomes for indigenous peoples.
Our take: This approach requires the most political capital, as it restructures how care delivery is coordinated and organized and the level at which decision-making happens. Establishing a dedicated entity to address indigenous health concerns is inarguably a step in the right direction towards correcting for historical injustices and inequalities. However, this can't be a 'one and done' solution. In order for the Māori Health Authority to achieve its stated goal of improving care quality and outcomes for indigenous groups, the government will have to ensure that it provides adequate funding and resourcing in perpetuity. If not, it runs the risk of repeating the failures of similar agencies in other jurisdictions. The jury is still out on how centralizing services at the national level will impact quality and outcomes across the country. Leaders from the dissolved agencies have expressed concerns that this approach may worsen regional disparities at it reduces the decision-making power of localities.
2. Expand public health access with a focus on underserved populations
Where it's happening: Chile
Why: In response to the 2019 protests against social inequities, Chile established the Constitutional Convention—a temporary federal agency—to draft a new constitution. In April 2022, the Convention voted to create a new national health service modeled after the UK's NHS. Chile's two-tier system has created tremendous inequality in access to and outcomes along socioeconomic lines. The stated goal of their newest reform is to provide better care for the vast majority of the population (80%) who relies on a presently under-funded public system.
How: Under the current dual health care system, all workers are required to contribute 7% of their income to fund health insurance. Coverage is offered by both public and private schemes. Both are tax-payer funded, but patients can opt into the private scheme—which grants access to private providers and clinics—for an additional cost. Although only 20% of Chileans opt for private coverage, private payers get 50% of the total tax funding available. Under the new system, all workers will pay into a single fund, funneling all resources—which are currently being split across multiple insurance schemes—into the national health service. The future of private payers under this new structure is still unclear, but some leaders suggest that they will "disappear from the health care landscape."
Our take: The reform channels all of the funding generated from the income tax into the public system, eliminating tax-based funding streams for private providers. This constitutes a win for the broader public who will now have access to higher quality of care from public providers, but an obvious loss for the private sector. In theory, patients will still have the option to pay out of pocket for care from private providers. However, if private payers do in fact "disappear," some early reports estimate that the number of staff in the private hospital sector may decrease by 11-33% percent. Because governments often partner with private providers to expand public sector capacity in times of crisis, this potential decrease in the number of private providers may limit flexibility in the system if the public sector is overwhelmed, harming health equity particularly in times of turmoil or crisis.
3. Target equity improvements using a population-by-population approach
Where it's happening: Ontario, Canada
Why: The pandemic exposed failures in aged care systems around the world. Ontario's aged care sector was ravaged by the virus due to overcrowding, poor working conditions, and staff and PPE shortages. This prompted a formal investigation, which revealed that a majority of deaths occurred in for-profit facilities.
How: In 2021, the Ontarian government proposed a new bill to reform aged care, following many of the recommendations set by the long-term care commission that was appointed to identify inefficiencies in the system. The proposal tightens regulations for private providers. If passed, the bill will enable the provincial government to take over operations of suspended care homes; increase average daily direct care from clinical staff to a minimum of four hours a day by 2025; mandate that palliative care become part of residents' care plans; and double maximum fines for homes that break rules.
Our take: These proposals are emblematic of Ontario's approach to improving care delivery--in 2019, the government introduced legislation that created integrated delivery networks that were initially focused on three target patient populations (each network chose its own three target groups). This approach continues on that trend, as it seeks to improve care for specific patient groups by targeting a segment of the care continuum. This approach is more palatable than broad reforms, as the scale of the changes is much smaller than the aforementioned options. It also enables governments to narrow their focus and target resources to specific groups that have been historically disadvantaged or disproportionately impacted by a crisis.
As governments continue to shift their focus away from Covid response towards broader ambitions to improve cost, quality, and access, we are interested to see which approach proves to be more successful: piecemeal policy solutions, or institutional reforms that reorganize the care delivery system.